Inspection on 12/01/09 for Hulcott Nursing Home

This inspection was carried out on 12th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hulcott Nursing Home 05/05/09

Hulcott Nursing Home 15/10/08

Hulcott Nursing Home 23/09/08

Hulcott Nursing Home 13/06/08

Hulcott Nursing Home 18/06/07

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 20/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hulcott Nursing Home The Old Rectory Hulcott Aylesbury Buckinghamshire HP22 5AX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Chris Sidwell     Date: 2 3 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Hulcott Nursing Home The Old Rectory Hulcott Aylesbury Buckinghamshire HP22 5AX 01296488229 01296330834 hulcott@caringhomes.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hulcott Limited The registered provider is responsible for running the service care home 49 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 49 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 2 5 0 9 2 0 0 8 Hulcott nursing home is located a few miles outside of the centre of Aylesbury in a quiet hamlet location overlooking a green. The home is registered to provide accommodation for up to forty-nine service users requiring nursing input. The building has been attractively arranged to provide a pleasant environment for the people living there, with good quality furnishing and fittings. Nine of the bedrooms are shared rooms for two people. The majority of bedrooms have en suite facilities and all but two rooms are fully wheelchair accessible. There are three lounge areas, a large conservatory and a quiet area by the main entrance. The grounds are well maintained with a patio area and backs onto farmland. There are no public transport links and shops are some distance away. Care Homes for Older People Page 4 of 35 Care Homes for Older People Page 5 of 35 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 inspection was conducted over the course of six days and included three days, the first of which was unannounced, in the home. The key standards for older peoples services were assessed. Information received about the home since the last inspection was taken into account in the planning of the visit. Questionnaires were sent to the home for distribution to residents and their families, health care professionals and staff. Sixteen residents or their families, three health care professionals and two members of staff returned the questionnaires. Where these were received before the inspection the comments were used to inform the planning of the inspection. Residents and families were spoken to on the day of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care Care Homes for Older People Page 6 of 35 practice was observed and the care of eight residents followed through. A tour of the building and examination of records was also undertaken. The homes approach to equality and diversity was considered throughout. The home last had a key inspection on the 19th June 2008, when the overall quality rating was good. Random focused inspections were undertaken on the 25 September 2008 and 15th October 2008, following a safeguarding alert made by the local hospital when a resident was admitted. These inspections showed a deterioration in care. A safeguarding inquiry was established by the local authority. The information from the care managers reviews and the strategy meetings, which were held subsequently, has also been used to inform this inspection. What the care home does well: What has improved since the last inspection? There has been an improvement in the way in which pressure damage is prevented, treated and monitored in the home since the last random inspection on 25th September 2008. There is a reduction in the number of people with pressure damage and no one has developed damage after moving to the home since the last random inspection. Six residents had pressure damage and the records showed that this was healing. The organisation has invested in new beds, base mattresses and specialist airflow, pressure relieving mattresses for those who need them. One family member said she was pleased to see the pressure relief being given. New scales have been bought and residents weight is monitored more accurately. The menus have been changed to incorporate full fat products and to increase the calorific content of the menu. The chef is aware of those who may lose weight. An extra dining room table has been put in the conservatory to enable more people to eat at a table rather than at small tables in front of their armchair. Staff have received additional training in the prevention of pressure damage, manual handling, continence and safe working practices. Care Homes for Older People Page 8 of 35 The organisation has strengthened the management structure of the home by appointing a deputy manager to manage the home in the absence of the manager. The quality monitoring systems have been improved and greater detail is now reported on the weekly and monthly management and risk reports. The operational manager undertakes a more thorough quality monitoring visit and has been a visible presence in the home during the last three months. What they could do better: The home must ensure that a full assessment is undertaken if they take people who have dementia, but whose physical needs outweigh this, to ensure that their current and future needs can be met and to ensure that they are working within their registration categories. The home must ensure that consistent care planning documentation is used for those who have pressure damage. Care plans must be updated when damage reoccurs and wound healing must be monitored consistently. The administration of controlled drugs must be monitored to ensure that not only are the stock numbers correct but that the prescription is being accurately followed, to ensure residents receive the medication they need at the intervals prescribed. There is need to review the menus to ensure that the choices available meet residents varied likes and dislikes. There is also a need to ensure accurate records are kept if menus are changed for any reason and the meal served is not that which is stated on the menu. The organisation must ensure that the heating system is reliable, to ensure that residents are warm. The wheelchair lift platform on the second floor must be repaired to enable residents who require a wheelchair to access the communal areas of the home. The bedpan and urinal washers must be repaired and brought back into use to minimise the risk to service users of acquired infection. Pedal operated bins with lids must be used to dispose clinical waste. The shower in Room 30 should be repaired. The minor defects and observations made at the lift inspection should be addressed. The safety recommendations for the boilers made at the insurance company inspection should be implemented. An action plan must be developed to address the issues raised in the Health Protection Agencys infection control audit and must be sent to us, to improve the standards of infection control and to protect residents from acquired infection. Care Homes for Older People Page 9 of 35 The home must be able to show that there are sufficient staff, available at all times, with the knowledge and skills to meet the needs of residents, when the home reopens to new residents, to ensure that residents health and care needs are met in a competent and timely way. All staff must have an induction programme, to ensure that they are knowledgeable about the care needs of residents and the way in which these should be met in the home. All staff must have up to date mandatory training in safe working practices to protect residents and staff from potential harm arising from their care. The organisation must ensure that where in house trainers are used that they update their skills regularly. There is a need to ensure that the quality of care and safety of residents is not compromised by the absence of key support staff and to demonstrate that they can provide continuity of management arrangements by supporting the manager to register with us in a timely way. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 35 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 35 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. There is information available for prospective residents and their care needs are identified with them, prior to their move to the home, to ensure that they can be met. Residents have contracts, which describe the service that they should expect and the responsibilities of both parties. The home must ensure that a full assessment is undertaken if they take people who have dementia, but whose physical needs outweigh this, to ensure that their current and future needs can be met and to ensure that they are working within their registration categories. Evidence: The home has information for residents in the form of a statement of purpose, service users guide and coloured brochure. The statement of purpose and service users guide had been updated within the last year and was displayed in the entrance of the home. It held information about the home and details of the complaints procedures should any one have concerns. Information about advocacy services was also available in Care Homes for Older People Page 12 of 35 Evidence: entrance hall for families and residents to access if they wished. The statement of purpose describes Hulcott as being able to offer care to service users with moderate, severe and complex nursing care requirements, users with high physical dependency, but not those whose mental health difficulties are so marked as to require specialised psychiatric support, (ie persons with diagnosed dementia prior to admission where their dementia outweighs their nursing needs). The home is registered with us as able to care for older people and does not have specialist dementia care registration. At the time of the inspection there were six people funded by the local older peoples mental health team. Their assessment documentation was checked and although not completed in full, four were found to have a diagnosis of dementia before moving to the home, although their mental health needs were not such that they required specialist care. The home must be careful to ensure that a full assessment is undertaken if they take people who have dementia to ensure that their current and future needs can be met and to ensure that they are working within their registration categories. The files of an additional six residents were examined. All had evidence that the manager or senior member of staff had visited them prior to their move to the home and that their needs had been assessed. There was evidence in the files that the care managers assessments had been sought where appropriate. Residents cultural and religious needs had been identified and recorded as part of the assessment. Fourteen of the sixteen people who returned the questionnaire said that they had received enough information about the home before they moved. Comments included I felt, although nothing perfect, Hulcott met my Mums requirements, the staff were friendly and caring, all questions asked were answered and I was shown around, I was able to visit freely, given a guided tour, a brochure and all my questions were answered and My late wife and I visited a number of homes in the area. In our opinion Hulcott was our choice, clean bright and well organised. Fourteen of the sixteen people who returned the questionnaire said that they had a contract with the home. The home offers respite care. The home does not offer specialist rehabilitation and intermediate care. Care Homes for Older People Page 13 of 35 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. There has been an improvement in the extent to which the home meets the health care needs of residents since the last random inspection. There is a need to consolidate that improvement and ensure that a consistent approach is taken to the recording and monitoring of pressure damage, to ensure staff are clear as to the actions that they should take to protect residents health and wellbeing. Controlled drugs should be monitored to ensure that not only are the stock numbers correct but that the prescription is being followed accurately to ensure residents receive the medication they are prescribed. Evidence: The care of six residents was followed through. The home is in the process of introducing a new care plan format which they feel will make the care plans easier for staff to follow and make it easier for them to update regularly. The health care and personal care needs of those reisdents whose care plans were reviewed were recorded. Basic risk assessments of residents nutritional status, their risk of falling and their risk of developing pressure damage had been undertaken. Of the sixteen people who Care Homes for Older People Page 14 of 35 Evidence: returned the questionnaires eleven said that they usually received the care and support that they needed and four said that they always received it. Comments were varied including Mum doesnt like to worry staff, as I visit regularly I make requests as needed and this is difficult to answer as we only we only see staff when we visit, however my mother who has Alzheimers seem happy and fond of staff. Others commented that there were occasions when the bell was not answered quickly but that although some staff are better than others, I have confidence in the home to do the best for my mother. One family member spoken to on the day of the unannounced visit said that she was very happy with the care her mother received and wished it to be recorded that her mother had improved since moving to the home and had put on weight. Two healthcare professionals returned the questionnaires. The general practitioner felt that the home usually met residents healthcare needs but had concerns about communication with staff whose first language was not English. The continence nurse advisor said that the home was working closely with her to ensure that residents continence needs were identified and met. She felt that residents were treated with dignity and respect. A requirement was made at the random inspection undertaken on the 25 September 2008 that residents weight must be monitored carefully and appropriate action taken to prevent weight loss. The documents seen showed that residents had been weighed on moving to the home and regularly since. Most people appeared to be maintaining their weight. There were some anomalies where people appeared to lose weight one week and gain it the next although the manager felt that this could be accounted for by the fact that new electronic scales had been bought. The chef had a copy of the residents weight list and was aware of those whose weight was monitored. The menu had been changed to include full fat products and to increase the calorific value of meals. Food and fluid records were being kept for those who needed support eating. At the random inspection carried out on the 29th September, eight people had been found to have pressure damage. Five requirements to improve this aspect of care were made, including that residents should be accurately assessed as to their risk of developing pressure damage, that they should have an up to date care plan which set out in detail the care that they needed and when it should be given, that the advice of the tissue viability nurse should be sought and that the organization should provide sufficient mattresses which are in good working order to allow all those at risk to have the appropriate mattress. The local Primary Care Trust has worked closely with the home to help them achieve these requirements. The tissue viability nurse and district nurse has visited regularly to advise and to monitor the progress the home has made in implementing new systems and to monitor the health and welfare of residents. Five Care Homes for Older People Page 15 of 35 Evidence: residents had pressure damage on the day of the inspection and one resident had a history of fragile skin which broke down easily. From the records and the organisations quality monitoring reports it appeared that three residents had pressure damage when they were admitted to the home and two acquired it in the home. None had acquired pressure damage since the last random inspection. All had been assessed accurately using a recognised pressure damage risk assessment tool. All had care plans although there was some inconsistency in the documentation in use and for one a lack of clarity as to how often the dressings should be replaced. Some but not all had photographs to monitor the progress of healing. Progress was either recorded on a structured monitoring sheet or evaluated in the ongoing care plan. One resident had developed a recurrence of his pressure damage recently and his care plan had not been updated to describe the care needed. The district nurse checked his dressing on the day of the inspection and said that the choice of dressing was correct even though it was not recorded clearly on the care plans. The photographs seen of other resolving pressure damage showed that the damage was healing. The home has invested in new base mattresses and specialised pressure damage prevention mattresses since the last inspection and those seen were in working order and set at the correct level. There has been an improvement in the recognition, prevention and management of pressure damage since the last inspection. There remains however a need to ensure that the documentation in use is consistent and updated regularly. This will be a requirement of this report. There are medication management policies and procedures in place and the staff spoken to were aware of these. A new clinical storage room has been established in an attic space in the home which has improved the storage facilities. There are handwashing facilities and the temperature of the room is monitored. The medication trolleys were were secured safely on the ground floor. Medicines received and leaving the home were recorded on the individual medication administration records. these records were accurately completed when medication was administered. Two of the charts seen showed that the residents were consistently refusing medication. The nurses spoken to said that coercion would not be used. There was no evidence in the care plans that these residents medication needs had been reviewed and the home should ask that this is done. A multi disciplinary team meeting had been held regarding one resident who consistently refused essential medication and it was agreed with her family and the general practitioner that this could be given covertly if necessary. Controlled drugs were stored correctly and all entries to the controlled drugs register were signed. The staff said that they were checked every day at handover. Two drugs were checked at random and one was found to be correct in all aspects. One resident however was prescribed a pain relieving patch dressing which should have been changed after 96 hours. This had been done on most occasions. The Care Homes for Older People Page 16 of 35 Evidence: medication administration chart had however been inaccurately annotated and on one occasion, according to the controlled drugs register, the patch had been changed after 3 days and on two occasions after five days. This was brought to the attention of the manager who agreed to check the prescription and address the issue immediately. Care Homes for Older People Page 17 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is responsive to the wishes of residents and their families and welcomes families at any time. Residents have a choice as to whether they join in the activities programme. Most residents enjoyed their meals although there is need to review the menus to ensure that the choices available meet residents varied likes and dislikes. There is also a need to ensure accurate records are kept if menus are changed for any reason. Evidence: There is an activities organiser in post who arranges a number of activities which residents are assisted to participate in if they wish or are able. A programme is placed on the noticeboard. The general activities on the week of the unannounced visit included a church service, a singalong and a coffee morning to meet the chef. The manager has put up bird tables which provide interest and diversion. A Burns Night celebration was planned. Residents or their families told us that activities were always or usually available. One resident said that she chose not to participate. A number of people commented that there were few activities suitable for people with dementia. Staff were observed to treat residents with respect and to be patient. One was seen to Care Homes for Older People Page 18 of 35 Evidence: diffuse a potentially difficult incident with a resident very well. Care is given in residents rooms and their privacy and dignity is respected. Staff spoke to residents gently and went up to them. Nobody was heard to speak to residents from the middle of the room or along the corridor. Residents and families who returned the questionnaires said that staff listened and acted upon what they say. Families spoken to said that they were made to feel welcome and could visit at any time. Some came regularly to spend time with their relative and were clearly relaxed and comfortable with staff. The menus are varied. There is a rotating menu plan although on both of the days of the inspection the meal served was not the same as on the menu plan. The chef was sick on one day and a carer had stepped in to cook the lunch and cooked a dish that she felt comfortable to cook. Most residents said they were enjoying their lunch on both days. One resident did not like her lunch and the chef willingly cooked her an alternative. The chef is very aware of residents nutritional needs and likes and dislikes and said that he could provide meals to meet residents cultural and faith needs if necessary. The menus have been revised to includes full fat products and increase the calorie value of the menu to help minimise weight loss. All food is home cooked and there was evidence that fresh fruit and vegetables are used. A bowl of fruit is taken around at tea time although few residents were seen to eat this. Staff were seen to assist residents discretely. Residents and families comments were mixed. Ten of the sixteen people who returned the questionnaires said that they usually liked the meals, two that they always liked the meals and three that they sometimes liked the meals. Two people commented that it always the same every week and we were assured the menus rotated over a four week cycle, this does not happen. The chef and manager said that they were working with residents to vary the menu and enable residents to choose the dishes that went on the menus. There is a need to complete this project and to ensure that there is a choice and that the menus are varied. The home is also required by the Care Homes Regulations, Schedule 14, to keep a record of the food provided for residents in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. A record must be kept if the meals offered are different from the published menus to ensure that accurate records are held and can be checked at inspection and as part of the homes own quality assurance programmes. Care Homes for Older People Page 19 of 35 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 organisation has systems in place to protect residents from harm. However these were not effective during a period when the manager was absent. The organisation has worked constructively with the local authority and other organisations to improve the quality of care and to put monitoring systems in place to prevent residents coming to harm in future. Evidence: There are complaints policies and procedures in place which are advertised clearly in the home. All the residents or their families who returned the questionnaires said that they knew how to make a complaint. One said that this was explained verbally, given in writing and displayed in the home. The manager said in the annual quality assurance questionnaire that she had received seven complaints in the year up to December 2008. These had been investigated in the timescales agreed and action plans had been developed. The Commission for Social Care Inspection has not received any complaints from residents or their families since the last inspection. A major safeguarding investigation has been initiated and run by the local authority following a safeguarding alert made by the local hospital in August 2008, when concerns were raised about the condition of a resident admitted to the Accident and Emergency department. Following two initial safeguarding meetings, when information from the home was limited, a Random Focused Inspection was undertaken by us on Care Homes for Older People Page 20 of 35 Evidence: the 25th September 2008. This revealed significant concerns about the homes ability to meet the health care needs of residents, in particular the prevention and management of pressure damage and a number of requirements to improve care were made. The issues of concern arose during the absence of the manager and were not identified quickly enough by the homes quality monitoring system to prevent residents coming to harm. The manager and senior management of the organisation has since worked constructively with us and with the Local Authority and Primary Care Trust to improve care and to meet these requirements. They have strengthened their quality assurance systems and agreed voluntarily not to admit new residents until the issues of concern had been resolved. The local authority has also reviewed the individual care of all residents and contacted their families to ensure that they are satisfied with the care offered. The investigation has almost concluded and it has been agreed that the home can resume admissions subject to ensuring that they assess new residents needs carefully and have sufficient staff and equipment available to meet their needs. A further meeting of the home and the agencies concerned is planned for June 2009 to ensure that the agreed improvements have been maintained over a period of time. The safeguarding meetings will be resumed if further information is received which indicates that there are still grounds for concern. Care Homes for Older People Page 21 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable and homely environment for residents. There is a need to ensure that services, including the heating, are reliable and that repairs are undertaken in a timely manner. There is a need to improve infection control practices if residents are to be fully protected from acquired infection. Evidence: The home is situated in a small village on the edge of Aylesbury. The ground floor rooms open on to the garden or small patios. Some of the external paintwork is in poor repair and needs repainting. There is a rolling programme of redecoration in the home and most communal areas have been redecorated. Bedrooms vary in size. Residents are encouraged to personalise them and many had chosen to do so. The home was clean and tidy on the day of the unannounced visit. There were no offensive odours in the hallways or rooms. The home has invested in height adjustable beds and new base and specialist matresses since the last inspection. We had been notified that one of the heating boilers was not working and part of the home was without heating on the first day of the unannounced visit. The boiler had not been working for 3 days. An engineer had been called when the boiler first Care Homes for Older People Page 22 of 35 Evidence: malfunctioned and was returning to repair it. The manager said that residents had been offered temporary rooms which did have heating and additional electric fan heaters had been provided for all residents who did not have heating in their bedrooms as well as extra blankets and duvets. The boiler was repaired by the end of that day. Records were checked and the boilers in the home had last been serviced on 27 July 2008 and inspected as part of the homes insurance policy on 8th September 2008. Recommendations for additional safety fuel shut off valves were made at the latter inspection and the facilities manager for the organisation has asked for quote for the installation of these and and for an upgrade of boiler plant to improve the reliability of the system. One boiler was noted as being made in 1995. The age of the other two boilers was not known. He stated that a decision to delay the installation of the improvements has been made to avoid decommissioning the system during the winter. The organisation must ensure that the heating system is reliable. The lift was inspected on the 10 November 2008 and although found safe to use there were a number of minor deficits and observations that should be addressed by the organisation. The wheelchair lift platform on the second floor was noted to be out of use and should be repaired. The shower room in room 30 had a notice dated 21st May 2008 to say do not use leaks being fixed. The shower did not have a shower head. This must be repaired. There was an offensive odour from the sluice on the second floor. The bedpan washer was out of order and the clinical waste bin did not have a lid. The manager stated that the other bedpan washer was also out of order and that she had reported these to the head office and raised a repair sheet. This has not yet been addressed. The bedpan and urinal washer on both floors must be repaired and pedal operated bins with lids must be provided for clinical waste. An infection control audit was undertaken by the Health Protection Agency and a number of recommendations were made to further improve infection control standards. An action plan to address these must be developed and sent to us. Care Homes for Older People Page 23 of 35 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. The recruitment procedures are thorough and should protect residents from unsuitable staff. There is a need to monitor staffing levels carefully to ensure that there are sufficient staff to meet residents needs as new residents move to home. There is also a need to ensure that all staff have a comprehensive induction and are up to date with mandatory training in safe working practices, to ensure that they can care for residents competently and safely. Evidence: The manager and operational manager said that the homes staffing levels were adjusted according to the dependency of residents. A dependency analysis is undertaken and the number of hours of care required is estimated from this. The analysis was not available on the first day of the inspection but two previous months analysis were available on the last day of the inspection. Scrutiny of the staffing rotas showed that the planned staffing levels had been reduced on the December to January rotas from 2 Registered Nurses and 7 carers on duty in the morning to 2 Registered Nurses and 5 carers on duty in the mornings. The afternoon and night staffing levels had remained the same with 2 registered nurses and 4 carers on duty in the afternoon/evening and 1 registered nurse and 3 carers at night. The planned rota for January to February showed that it was expected that these staffing levels would be continued. The rota showed that approximate 20 shifts remained to be covered by Care Homes for Older People Page 24 of 35 Evidence: permanent staff undertaking overtime or bank or agency staff. The manager and operations manager said that the staffing hours planned met the homes current dependency analysis requirements and the reduction was due to the reduced number of residents since the voluntary agreement to temporarily stop accepting new residents to the home. They also said that they were in the process of recruiting 7 new members of staff whom they had interviewed and were awaiting references and Criminal Records Bureau disclosures. The manager and operations manager agreed to monitor staffing levels carefully when the home reopened to admissions to ensure that they could continue to meet the needs of residents when the occupancy increased. They said that initially they may take two residents who they already knew and who came for respite care. It is a requirement of this report that staffing levels are monitored carefully throughout the period when the home reopens and that the home can demonstrate that it can meet the helath and personal care needs of residents as occupancy increases. The training records were not up to date as the administrator had been sick and the manager had worked in the home on the care rota during the period when care standards were under review. From the information available it appeared that 90 per cent of staff had had manual handling training. The home has an in house trainer to undertake this training. It was unclear when her train the trainer training had been updated. The manager said that if she was unavailable staff would go to another home or a member of the organisations central training team would be available. Compliance with other mandatory training in safe working practices varied from 48 per cent of staff having food hygiene traing and 80per cent of staff have fire training. The organisation must ensure that all staff have mandatory training in safe working practices. The organisation must also ensure that where in house trainers are used it can be shown that they have updated their skills on a regular basis. The records showed that 31 per cent of care staff hold the National Vocational Qualifications in Care at Level 2. The home does not yet meet the standard that 50 per cent of staff hold this qualification. The recruitment files of three recently recruited members of staff were reviewed. All had the required documentation to show that checks as to the potential staff members identity and suitability to work with vulnerable people had been undertaken. All had submitted an application form, which showed their work history. Criminal Records Bureau checks had been undertaken before the staff member commenced work. There was evidence in the files seen that work permits had been obtained where necessary. Two references had been obtained, one from the previous employer. The files showed that staff had undertaken a local induction programe although not a structured programme which met the skills for care standards. Only two members of staff Care Homes for Older People Page 25 of 35 Evidence: returned the questionnaires and neither said that they had had an induction when they started. The staff spoken to said that they had been shown around and worked with another carer for sometime when they first started. They confirmed that they had had moving and handling training and safeguarding training. Care Homes for Older People Page 26 of 35 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 organisation has strengthened the management structure of the home and improved the quality monitoring systems to assure the quality of care. There is a need to ensure that the quality of care and safety of residents is not compromised by the absence of key support staff and to demonstrate that they can provide continuity of management arrangements by supporting the manager to register with us in a timely way. Evidence: There is an experienced manager in post. She is a registered nurse and is currently studying for the National Vocational Qualifications in Management at level 4. She was appointed to the home in March 2008. The organisation has not yet applied for her to be registered with us, as is required. The operational manager said that the application documents were complete and would be sent when the cheque for payment was received from the organisations head office. An application has not been received at the time of writing this report. The organisation has not registered a manager with us Care Homes for Older People Page 27 of 35 Evidence: since they took over the home 2006. Whilst there has always been a manager in place or an acting manager none have registered with us. This must be addressed and the organszation must demonstrate that it can provide continuity of management and meet the requirement of the Care Standards Act 2000 that the manager registers with us. A requirement was made at the last inspection that the organisation ensured that suitable arrangements were in place to manage the home in the absence of the manager. A deputy has now been appointed and the organisation has agreed that an experienced temporary manager will cover the managers forthcoming holiday until the deputy has completed her induction and is familiar with the home and the needs of residents. Requirements were also made that the organisation ensure that regular quality monitoring visits are undertaken and that their quality assurance systems identified deterioration in the care that residents received and that prompt action was taken to address it. A new format has been introduced for the visits undertaken by the operational managers has required by Regulation 26 and greater detail is included in the weekly and monthly management and risk reports made by the home to the organisations clinical governance team. There was some evidence that issues are being picked up. For instance the operational manager identified that the maintenance safety checks were not up to date since the maintenance officer left and arranged for a site maintenance officer from another home to come to the home and reinstate the checks and update the files. The reports of two visits undertaken in November and December 2008 show that the operational manager spoke to the manager and a small number of residents as part of her review. It is recommended that she speak to a wider range of staff and seek the views of more residents when undertaking her quality monitoring visits. The visits should also be unannounced. A requirement was also made that we are notified of serious untoward events which affect residents and of incidents when they may have suffered harm. This has now been reinstated and appropriate notifications are being made. There was evidence that the manager is holding regular staff and resident/family meetings and minutes are available. The home does not manage any monies on residents behalf. Any items of expenditure, newspapers, hairdressing are invoiced to the resident or their family as part of the billing system. There are health and safety policies and procedures in place and incident reporting Care Homes for Older People Page 28 of 35 Evidence: systems. The maintenance of essential equipment and services is coordinated by the organisations head office and evidence that the services had been maintained was not initially available in the home. This was rectified and information from the facilities manager was sent to the home. Routine safety checks for fire safety and other checks had not been maintained since September 2008 because of the sickness of the maintenance officer and his subsequently leaving the home. A maintenance officer from another home in the group had been asked to come to the home to reinstate these and to bring the files up to date. He was in the process of doing this and had undertaken all the necessary fire safety checks, with the exception of the emergency lighting for which he required additional information. The water temperatures for the baths and showers were checked at random on the day of the unannounced visit. The bath temperatures were found to be in the correct range. The shower temperatures were found to be running at 60C and 56C. This is above the safety recommendations of 43C and could have caused scalding. There were no thermometers in the shower rooms and the carers spoken to said that they tested the temperature on their forearms. This was brought to the attention of the manager immediately and an order for thermostatically controlled restrictors was placed. The organisation must ensure that safety checks are undertaken in the absence of the maintenance officer and that the manager is supported when key members of support staff are sick or not in post. Care Homes for Older People Page 29 of 35 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 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The home must ensure that a full assessment is undertaken if they take people who have dementia, but whose physical needs outweigh this To ensure that their current and future needs can be met and to ensure that the home is working within their registration categories. 31/03/2009 2 7 15 The care plans of those 27/03/2009 residents who have pressure damage must be updated regularly and a consistent approach to evaluating progress in wound healing must be adopted. To ensure clarity for staff as to how they should best meet residents care needs. 3 9 13 The administration of 27/03/2009 controlled drugs should be monitored to ensure that not only are the stock numbers correct but that the Page 31 of 35 Care Homes for Older People prescription is being accurately followed. To ensure residents receive the medication they need at the intervals prescribed. 4 15 17 A record must be kept if the 27/03/2009 meals offered are different from the published menus. to ensure that accurate records of the food offered to residents are held and can be checked at inspection and as part of the homes own quality assurance programmes. To ensure that residents diets are varied and nutritionally satisfactory. 5 19 13 The bedpan and urinal washers must be repaired and brought back into use. To minimise the risk to service users of acquired infection. 6 19 13 Pedal operated bins with lids 27/03/2009 must be used to dispose clinical waste. To minimise the risk of the spread of infection. 7 22 23 The wheelchair lift platform on the second floor must be repaired. To ensure that the area is accessible to those who need a wheelchair. 8 25 23 The organisation must ensure that the heating system is reliable. 27/02/2009 27/03/2009 27/03/2009 Care Homes for Older People Page 32 of 35 To ensure that residents are warm. 9 26 13 An action plan must be 27/03/2009 developed to address the issues raised in the Health Protection Agencys infection control audit and must be sent to us. To improve the standards of infection control and to protect residents from acquired infection. 10 27 18 The home must be able to 27/02/2009 show that there are sufficient staff,available at all times, with the knowledge and skills to meet the needs of resident, when the home reopens to new residents. To ensure that residents health and care needs are met in a competent and timely way. 11 30 18 All staff must have an induction programme. To ensure that they are knowledgeable about the care needs of residents and the way in which these should be met in the home. 12 30 18 All staff must have up to date mandatory training in safe working practices. To protect residents and staff from potential harm arising from their care. 27/03/2009 27/02/2009 Care Homes for Older People Page 33 of 35 13 30 18 The organisation must ensure that where inhouse trainers are used that they update their skills regularly. To ensure that staff have the most up to date advice on safe working practices. 27/03/2009 14 31 8 The manager must register with us. To comply with the requirements of Section 11(1) a of the Care Standards Act 2000. 31/03/2009 15 38 13 The essential safety checks must be undertaken regularly. Water outlet temperatures particularly in showers and baths should be close to 43C to minimise the risk of scalding. To protect residents from the risk of scalding 27/02/2009 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 2 3 4 21 22 22 33 The shower in Room 30 should be repaired. The minor defects and observations made at the lift inspection should be addressed. The safety recommendations for the boilers made at the insurance company inspection should be implemented. The operational manager should strengthen the quality monitoring visits by speaking with more staff and residents on her visits. Care Homes for Older People Page 34 of 35 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. 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