Inspection on 09/09/09 for Laurieston House

This inspection was carried out on 9th September 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Laurieston House 22/10/08

Laurieston House 03/10/07

Laurieston House 03/10/06

Laurieston House 15/11/05

Laurieston House 13/07/05

Laurieston House 13/12/04

Laurieston House 06/05/04

Laurieston House 14/10/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

Key inspection report Care homes for older people Name: Address: Laurieston House 78 Bristol Road Chippenham Wiltshire SN15 1NS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Walker     Date: 1 1 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Laurieston House 78 Bristol Road Chippenham Wiltshire SN15 1NS 01249444722 FP01249444722 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Jennifer Jobbins care home 9 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accomodated is 9 The Registered Provider may provide the following category of service only: Care Home only (Code PC) to service users of either gender whose primary needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) - maximum of 3 places Date of last inspection Brief description of the care home Laurieston House is a care home for up to nine older people, three of whom may have a dementia. The home is a two storey, detached property in a residential area of Chippenham. There is a large garden at the rear of the home and a parking area at the front. Laurieston House is owned by Mrs J. Jobbins, who is also the registered manager. There is a staff team which includes a deputy manager, senior carers and carers. Other staff members are deployed to carry out domestic work. Peoples accommodation is on the ground and first floors. There are four double rooms Care Homes for Older People Page 4 of 38 2 2 1 0 2 0 0 8 3 0 Over 65 3 9 Brief description of the care home and two single rooms. There is a staircase, but no lift, to those rooms on the first floor. The communal areas consist of a lounge and a dining room. Information about Laurieston House is available in the homes Statement of Purpose. The fees for the home are between 440.00 and 510.00 pounds a week. Copies of inspection reports can be obtained from the home. These are also available through the Commissions website at: www.cqc.org.uk Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced Key inspection started on 9th September 2009 between 9:10am and 4.35pm. As Mrs Jobbins was due to work the waking night shift that night, we went back to the home on 11th September 2009 to complete the inspection. Mrs Jobbins, registered provider and manager was present throughout the inspection. On the first day of the inspection we were accompanied by an Expert by Experience. Experts are people of all ages, from different backgrounds, who have different experiences of using care services. They speak with people who use services and help us improve the way we inspect. We do not directly employ Expert by Experience. The Expert spoke with people who live at the home and staff to gain their views on the service. Their findings are included in this report. As part of the inspection process we sent survey forms to the home for people who use the service, staff and healthcare professionals to tell us about the service. Comments Care Homes for Older People Page 6 of 38 are found in the relevant part of this report. We asked the home to complete an Annual Quality Assurance Assessment (known as the AQAA). This was their own assessment of how they were performing. It told us about what has happened during the last year and about their plans for the future. We looked at the information we had received since the last inspection in order to determine what to focus on during this inspection. The last Key inspection was 22nd October 2008. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: Care plans must be more detailed about how individual peoples risk of developing pressure damage is to be met and monitored. Referring to the policy and training documents is not sufficient as peoples individual needs will be different. Care Homes for Older People Page 8 of 38 The home should seek advice on supporting people to walk about the home in a better way. Staff walking backwards holding both hands may put both parties at risk. The home should also consider purchasing a hoist so that people can be moved more safely and staffs health and safety is assured. The home should consider whether the practice of putting everyones name in the toileting book is person centred care, particularly for those people who are described as self caring. There must be a clear written policy for the use of listening devices, so that peoples privacy and dignity are protected. The records of all transactions for money kept on peoples behalf must show a balance after each transaction. The arrangements must be audited more regularly, so that people know the home keeps their money safely. Although there is a bathing policy in place, care plans would benefit from being more personalised, as some people may wish to bath without staff support. People are at risk of being deprived of their liberty. The practice of locking bathroom doors when people cannot use the lock themselves must stop. If staff want to make sure that no one else uses the bathroom, they should stay close by. Until the upstairs window openings are properly restricted, people remain at risk of falling out. Locking the windows means that people cannot enjoy fresh air. Records should be kept of discussions with people as to whether they have made a positive choice to share the double bedrooms. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 38 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The statement of purpose was reviewed and revised when Mrs Jobbins applied to vary the categories of registration. It now shows what the service can provide. Peoples needs are assessed before they move in. Evidence: Action had been taken to address the requirement we made that the statement of purpose should be reviewed and revised to state the range of needs that can be met. This document was amended and sent to our registration department as part of Mrs Jobbins application to vary the homes category of registration. The statement of purpose stated that the home could meet the needs of three people with mild to moderate dementia. Mrs Jobbins or the deputy manager carried out the pre-admission assessments. There was good detail about the needs of people who were considering using the service. Care Homes for Older People Page 11 of 38 Evidence: We saw that care plans were in place on the day that people moved in. In a survey one of the people who use the service told us [We] went to look at least 3 other care homes. Laurieston stood out for their warmth, care and cleanliness towards their patients, it is like home from home. Care Homes for Older People Page 12 of 38 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning is more person centred with better detail about how people want their care to be provided. People have good access to healthcare professionals. Systems are in place to make sure peoples medication is handled safely. Evidence: In a survey one of the people who use the service told us takes care of all my needs. Looks after me well. Another person told us looks after my needs and comfort. One of the people who used the respite service told us all good. One of the relatives told us first class care. Treated with respect and dignity, all needs. Clinical notes, care plans, review. Support for family, sign posting to agency. Continuous education training to help ever changing, challenging changes, physical or mental. Makes sure GP reviews [my relative] on a regular basis. Multidisciplinary approach, works with the doctors and family. Good food, social activity, cleanliness, small and able to give full attention, no patient unattended. As I have said before, Laurieston is a first class home where all individual needs met. It is always clean and tidy and hygienic. They have always been flexible, nimble and have always risen to Care Homes for Older People Page 13 of 38 Evidence: the challenge and met [the residents] and family needs. I will always be in debt to the staff at Laurieston. Laurieston cares and support residents and families so we are able to feel reassured that our loved ones are in the best possible place. Laurieston is the best. One of the GPs told us in a survey provides a homely caring environment for the two patients of mine who reside here. Another GP answered usually to questions about monitoring and reviewing needs, seeking and acting on advice, medication and privacy and dignity. They ticked: dont know to the question about whether the managers and staff have right skills and experience. They said no concerns had been raised and Clients appear to be happy and well cared for. Two other GPs said always to all questions answered with no comments made. We found that peoples care and support needs were generally set out in their care plans. Most care plans showed guidance to staff on how they should meet those needs. The care plans were regularly reviewed and any changes signed and dated. All staff were required to sign up to each persons care plan. We saw that people had statements about capacity in their care plans. Mrs Jobbins had introduced a new section in the care plans entitled Aspirations. This had statements about what people wanted to do, for example; I want to keep in touch with family and friends and I want to keep walking. People had night care plans which stated that they would tell staff when they wanted to go to bed. There was good information about what support people needed at night and when they liked to have their early morning cup of tea. Risk assessments had been carried out with daily living activities, for example, moving and handling, falls, swallowing, use of the call alarm, making tea in the kitchen and needing staff members to accompany them if they went out. People had their risk of developing pressure sores assessed. Pressure relieving equipment was in place and identified in care plans. Care plans were less detailed about how any risks of developing pressure damage were to be managed; just the statement carry out pressure care in accordance with the policy and procedure information from training in ulcer prevention. Cream buttocks. We said that care plans must be more specific as each persons risk would be different. Mrs Jobbins told us that she had requested the tissue viability nurse to visit to give advice on Care Homes for Older People Page 14 of 38 Evidence: treatment of one person who was at high risk of developing pressure damage. She went on to say that the persons skin was in tact and there was a turning chart so that the person was not lying or sitting in the same position for long periods of time. Body maps were used to show any marks or skin discolouration. Mrs Jobbins told us that she had managed only three pressure sores in twenty years. The people had acquired them in hospital and the home had managed their healing with support from the community nurse. Action had been taken to address the requirement we made that hairbrushes and combs must not be used communally. People had individual storage boxes for their toiletries. There were no hairbrushes or combs in the chest of drawers in the bathroom. The Expert by Experience told us: All the residents were well dressed and clean some of them had their nails manicured by the carers. I think the home is very clean and the residents are clean and tidy and well looked after. The staff are respectful and treat the residents with dignity but that something more is missing. The Expert by Experience told us that whilst talking to people a young carer stood by listening and said I have not heard that before. The carer seemed a bit lost and then went off to ask if some of the other residents needed the toilet. There seemed to be a lot of toileting going on. We saw that there was a book for staff to record when people went to the toilet. Everyones names were in the book, despite people being described as not needing staff assistance. Action had been taken to address the requirement we made that care plans must identify how any behaviours are to be managed. We saw that one person had a written behaviour management plan. Some action had been taken to address the requirement we made that bathing risk assessments must identify how long people should be left unattended. We saw a record that one person enjoys an early morning bath. There was no record of whether staff supported them with bathing or if they could be left alone in the bath. There was a general policy in place that no one is left in the bath unattended. We said that this must now be personalised for each individual in their care plan. This is because some people may like to spend time in the bath on their own without staff. We saw in the AQAA that two people had been identified as having communication difficulties. We saw that their care plans identified how these people communicated and how staff should communicate with them. Mrs Jobbins told us that she had obtained information and documentation about using Care Homes for Older People Page 15 of 38 Evidence: the MUST (Malnutrition Universal Screening Tool), so that a risk assessment could be carried with peoples nutrition. People were regularly weighed. Mrs Jobbins told us that currently people did not need fluid charts. The Expert by Experience told us that one person was promised a cup of tea and a biscuit at about 11 am. She really wanted a drink but drinks were brought in for the staff and she was told she would get hers later and a biscuit. I was not in the room when this happened; glasses of water were about in the room. [Later a member of staff] came in and offered [the person] chicken or fish for lunch and said she would have a chocolate biscuit with her coffee to fatten you up a bit. The coffee arrived with some sort of mousse the young carer left it on [the persons] tray. No chocolate biscuit was offered and [the person] tried to eat the mousse by drinking it. I am not sure if the young carer was embarrassed by my being there but she left very quickly and left [the person] to it. I asked [the person] how she felt about the carers she said the younger ones dont chat. Action had been taken to address the good practice recommendation we made that phrases such as good pressure care, two carers to transfer, needs assistance when standing, and suitable diet should be expanded upon, so that all staff are supporting people in the same way. We saw that care plans and daily reports were more detailed and did not contain the unclear statements that we saw at the last inspection. In the AQAA Mrs Jobbins told us We ensure doctors are informed when a person takes up residency. We saw a letter in one persons file requesting medical history from a GP. One person had regular blood tests by the district nurse to make sure their medication suited them. Mrs Jobbins was administering medication when we arrived at the home. She showed us the new cabinet she had purchased to hold the medication. We saw that the supplier had confirmed that the cabinet met Misuse of Drugs regulations. However this was not the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007. We gave Mrs Jobbins our guidance document on controlled medication. Mrs Jobbins told us that she would contact the company about the cabinet supplied. We saw people receiving their medication at other times during our visits. Staff members checked peoples medication against the medication administration record before taking the record and the medication to the people who were receiving their medication. The home kept data sheets supplied with the medication, which highlighted any adverse effects which could occur. Care plans contained guidance about the application of topical creams and eye drops. We saw that there was a policy for the safe administration of medication dated 6th September 2009, which all staff Care Homes for Older People Page 16 of 38 Evidence: had signed up to. We saw that the induction policy stated that staff who were between the ages of 16 to 20 did not administer medication. In the AQAA Mrs Jobbins told us all staff that administer medication have received appropriate training in house and have attained certificates in safe handling of medication. Any resident that wishes to administer their own medication is assessed and monitored daily, limited amounts of medication are given to the resident (normally two days medication then reviewed and checked with the view to the resident having longer control over their medication to one week, this medication would be kept in a special cabinet. No one was currently administering their own medication. Staff had certificates in safe handling of medication. Action had been taken to address the requirement we made that written confirmation must be obtained from a GP if peoples medication is to be crushed and administered in food. Action had also been taken to address the good practice recommendation we made that if a GP or anyone suggests crushing medication, alternative preparations such as a liquid or dispersible medication should be requested. Mrs Jobbins told us that the person who had requested that their medication was crushed, now took no prescribed medication. Mrs Jobbins told us that she would always ask the GP to put varying prescribing instructions in writing. Care Homes for Older People Page 17 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good access to things to do in their locality. People enjoy the meals provided. Evidence: In a survey one of the people who use the service told us everything possible is done to make my stay as happy and comfortable in all respects. Wherever and when ever possible they make sure the residents socialise by visits to town, shopping and visits to cafe for coffee and always find time to chat no matter how busy they are. Another person told us Jenny [Mrs Jobbins] and her team are always there for you. They always have a smile and are willing to give you any help or advice that is asked for. Jenny treats each patient as a person just as though they are one of her family, not as a number like some other care homes I have visited. Well done. I would have had no hesitation in putting [another relative] into Laurieston House [if they were alive today]. The care there is excellent. One of the relatives told us excellent home. Looks after residents really well. Possibly more activities but this could be difficult for some residents. Very happy with the way my mother is cared for. Care Homes for Older People Page 18 of 38 Evidence: We saw that care plans identified peoples social histories and what their interests and hobbies were. A record was kept of what activities people were involved in each day. Mrs Jobbins told us she was planning the autumn activities. One person had come for the day service to have a meal and join in with the activities. In the AQAA Mrs Jobbins told us we ensure individuals keep in touch with the wider community by regular contact with their family, shopping, lunch, tea at the local hotels, church, dance shows, parties or walks to the local shops. We may start a monthly or six weekly in house magazine. Mrs Jobbins told us that some people liked to walk in the local park or go to watch the cricket matches on the pitch opposite. She said that people liked to go to a local hotel for coffee and shopping in Chippenham. One of the staff told us that people used their taxi tokens for some trips out. Mrs Jobbins told us that she would also use her car to take people out. Mrs Jobbins showed us a cupboard containing skittles, board games and painting materials. Care plans identified some of the activities that people had been involved in; cooking; folding laundry and going to a supermarket. People had been involved in potting up the patio plants. Mrs Jobbins showed us a doll that she had purchased. She told us about how different people accessed the dolls. There is research based evidence that anxiety can be reduced in some people with a dementia with doll therapy. There was a collage displayed in the hall which people had done. On the second day we visited people had a singing session in the sitting room. In the AQAA Mrs Jobbins told us we have continued to ensure our residents have access to a social/normal daily life outside of Laurieston House. Residents have a choice in activities provided and whether they choose to join in these activities inside or outside Laurieston House, we respect the individuals wishes and decisions. We permit residents to make choices with the decor,menus,activities,parties and how THEY wish to spend their day. Mrs Jobbins told us that staff were aware that peoples capacity to make decisions and choose, could change from day to day. Mrs Jobbins told us that she was a qualified masseur and would give people a hand and foot massage. One of the staff members was also a qualified masseur. One of the people we spoke with told us a hairdresser regularly visited the home. In their report the Expert by Experience told us: a large ball was being bounced between two residents and the young girl hung back not really interacting. [One persons] comment was how strange playing ball inside - this does not usually happen. We asked Mrs Jobbins about the ball game. She told us that it had been recommended by the physiotherapist for better hand and eye co-ordination. Care Homes for Older People Page 19 of 38 Evidence: The Expert by Experience to us the TV was off and music was playing some of the time, apparently the TV goes on after supper because the residents like to watch soaps and who wants to be a millionaire. [One person] told me I cant walk any more and I get very fed up, I have a TV in my bedroom but cant switch it on. [The person] loved sport when she was younger and loves to watch tennis. She told me she got up each morning at 6 am. [The person] loves to play scrabble and one of the carers told me they have to have a dictionary near them when she chooses her words and she was usually right. I asked her about other activities and if she would like to use a computer, at first she said no but when I told her about the elderly people in my tea party group that were frightened of the computer but now love it she listened to me. I think it would be one way the younger carers would be able to interact. I asked [another person] if she joined in down stairs and she said it is a waste of time they are mostly asleep and there is no one to talk to. I asked if she had lunch in her room and she said yes I usually just stay here. The Expert told us that a basket of towels was brought to one person [they were] asked to fold it, which she did, another carer folded it again, I felt this was demeaning! Apparently some of them are allowed to wash up too. This seemed to be seen as a treat. One person told the Expert by Experience I had to stand in the bank with a carer and was not really able to go to the shops I wanted to. Another person told the Expert by Experience I come here to give my daughter a rest it is very friendly. The Expert told us There was fresh fruit on the table in the dining room no one had any to eat and they would not be able to get to it if they wanted it. Mrs Jobbins told us that people could help themselves when they wanted. We asked about those people who could not walk independently to the dining room or stand to reach the bowl. Mrs Jobbins told us that they would be offered fruit throughout the day. In the AQAA Mrs Jobbins told us that the menus included three fresh vegetables meat,fish, all meals are cooked fresh each day - cake,biscuits, fresh fruit, coffee, tea squash snacks throughout the day, night. On the first day the lunch was roast chicken and vegetables with apple and blackberry pie and custard for pudding. Mrs Jobbins told us that some of the people who use the service had made the fruit pie on the Monday as a cooking activity. On the second day people had fish or sausage and chips from the chip shop. On both days people told us they were enjoying their meal. Action had been taken to address the requirement we made that records must be kept of any changes to the menus. We saw that any changes had been written in the homes daily diary. We also saw in the activity diary that people had been consulted about the menus. Mrs Jobbins told us that people chose to have a buffet night at least Care Homes for Older People Page 20 of 38 Evidence: once a week. This meal would be served to people in the sitting room; sandwiches; cake and crisps. When we first arrived at the home four people were having their breakfast. Mrs Jobbins told us that breakfast was served mainly in the dining room from 6.00am to 9.00am. The Expert by Experience talked with people about the meals. They told us: I asked if [they] had a choice of food and [they] said they were given their food if they did not like what was on the menu someone made them something else. One woman had a horrible bib on that looked like a slide it went around her neck onto the table and turned into a place mat, I would not like my Mum to be treated like that. On arrival Mrs Jobbins reminded me that we were in the residents home and to remember that. The sentiment is good, I have been into homes where the homes might not be as clean but the love in the home was overwhelming and I think this is what is missing. This home does not seem to have a heart. Care Homes for Older People Page 21 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A complaints procedure is in place. A better system for recording and auditing any money held on peoples behalf would mean more open accounting. Staff are trained to report any allegations or observations of abuse. The use of listening devices without a clear policy means that peoples privacy and dignity are compromised. Peoples liberty is restricted if they cannot get out of the bathroom unaided when the door has been locked from the outside. Evidence: The home had a complaints procedure. Mrs Jobbins told us that as a small home people would come directly to her to discuss any issues. She told us that there had been no complaints. She went on to say that records of complaint investigations would be recorded in her personal diary which she showed us. This also recorded any marks or bruises found on people. We looked at the arrangements for safekeeping of any money on peoples behalf. Peoples money was kept in purses and any transactions recorded in a note book. We checked the monies with Mrs Jobbins and found that the balances were in excess of the amounts recorded. The records did not have a running balance recorded; this was only recorded after a few transactions. We suggested that another column was added so that the balance could be recorded each time. Mrs Jobbins told us she would audit all the accounts with the deputy manager when she returned from leave. No valuables were kept on peoples behalf. Care Homes for Older People Page 22 of 38 Evidence: We saw that the staffing policy stated that anyone using a mobile phone on duty would be subject to disciplinary proceedings. We asked staff about what they would do if they saw or were told about abuse of people who use the service. They were quick to tell us that they would report any allegations or observations of abuse to Mrs Jobbins. They were also aware of the local safeguarding procedure and that they must let us know. Training records showed that staff had received training in the protection of people who may be vulnerable in April 2009. We saw that listening devices were being used with some people. We were told that this was so that staff could monitor peoples safety during the night. One of the staff told us that they were never used during the day. We looked at one persons care plan which only stated that it was used at night. There was no clear guidance about its use. We said that there must be a policy on the use of the listening devices. This must clearly state when they are to be used and turned off for peoples privacy. We also said that each person must have details in their care plan of their individual needs in terms of requiring the listening device. We asked Mrs Jobbins about the screwdriver, seen by the Expert by Experience, on the top of the fire alarm box. Mrs Jobbins got the screwdriver out of a drawer in the upstairs bathroom. She told us it was to turn the lock on the bathroom so that one person who had requested to be locked in, could have privacy when using the bathroom and toilet, if they could not use the inside lock themselves. We were concerned peoples liberty may be restricted if they could not use the lock on the inside of the door and had to wait for staff to let them out. We looked at bedroom doors and found that they had no locks. Care Homes for Older People Page 23 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a homely and clean environment. The environment is gradually being upgraded. Until the window openings to the first floor are properly restricted, people remain at risk from falling out. Locking these windows means that people cannot enjoy fresh air. Evidence: The homes statement of purpose stated that there were three single and three double bedrooms. There was no written evidence to show that people had chosen to share a bedroom or how the relationship was working out. The Expert by Experience told us in their report: I arrived at the home, rang the door bell and waited and waited, a lady arrived bringing her mother for respite care and advised I should push the door bell harder, perhaps it had not worked. The outside of the home either had last years Christmas lights still up or perhaps they light up the home at night? A young girl finally opened the door and apologised for the wait. I waited and the young carer waited, not sure what to do. I was not asked to sign in. Although the home is very small even I got confused over the doors and who was where; there did not seem to be any numbers or names on the doors, one door had a large butterfly on it. They went on to describe the sitting room: The room was very clean and cosy although dark. [One person talked] about not getting to the toilet in time she uses her bell but is not able to get to the toilet on her own. The toilet was a Care Homes for Older People Page 24 of 38 Evidence: weird shape and it would not be possible to get to the small hand basin to wash her hands after using the toilet. Her room was very clean with a new collage of her family photos on the wall. We saw that the dining room had been fitted with new carpet, a new dining room table and chairs and new sideboard and dresser. The room had also been redecorated. In the AQAA Mrs Jobbins told us that two bedrooms had also been refurbished. She went on to tell us of the plans submitted for a passenger lift to be installed in the near future. There were also plans for a new bath hoist. In her quality action plan Mrs Jobbins told us that one of the bathrooms would be refurbished by November 2010. She also told us that two bedrooms and the stairs and hallway would be refurbished by June 2010. We looked at the call bell system. There were signs on each floor which indicated on which floor the alarm was activated. A light above each door would then indicate in which room the alarm had been activated. Staff had to go into the room to turn off the alarm. This meant that they would see the person who was calling to respond to their request. In her quality action plan Mrs Jobbins told us she hoped to replace the existing call bell system by November 2010. We saw a risk assessment for use of one persons recliner chair. This had been regularly reviewed and signed and dated. As the person could use it themselves, there was no restriction to their liberty. Action had been taken to address the requirement we made that laundry must not be placed on electrical equipment. We saw no laundry placed on the pipe work of the hot water tank in the laundry. Mrs Jobbins told us that she intended to replace the boiler in the near future. She also said that the laundry room would be refurbished during this time with more storage space for laundry at different stages in the washing and drying process. At previous inspections we had made two requirements about the safety of the upstairs windows. One was that the windows to the first floor must have their openings restricted so that people were not at risk of falling out. The second requirement was that people must be able to safely open the windows to the first floor. We made this second requirement because the windows did not have fixings restricting their opening and as a result the windows were locked shut. We saw that restrictors had been fitted to the windows. However the fixings were a catch that could be easily be released so that the window would open further. We said Care Homes for Older People Page 25 of 38 Evidence: that this fixing was not sufficient to prevent people from falling from the windows. Mrs Jobbins told us on the second day that she had asked the Environmental Health Officer to visit to check the windows and give advice on suitable fixings. On the second day we gave Mrs Jobbins information from the Health and Safety Executive about the incidence of people falling from upstairs windows in care homes and advice about what to do to minimise the risk. Mrs Jobbins told us she would tell us what the Environmental Health Officer had advised. No confirmation has been received at the time of writing. Action had been taken to address the requirement we made that staff must be made aware of infection control guidance when dealing with clean and soiled laundry. In the AQAA Mrs Jobbins told us that fourteen staff had completed the infection control course. We saw that the laundry baskets were still being stored on the sink in the laundry room. Mrs Jobbins told us that the sink was not used for sluicing any laundry as there was no need. She said she may consider having the sink removed as it was not used, when the works to upgrade the boiler were carried out. Care Homes for Older People Page 26 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Many of the staff have worked at the home for some time and are well known to people who live there. A robust recruitment process is in place. Working boundaries for new staff are now clearly identified. Staff training is improving. Evidence: Mrs Jobbins was on duty with two members of staff when we first arrived at the home. One staff member was cooking the lunch. The staffing rota showed a minimum of three staff members during the morning and two staff members during the afternoons and evenings. At night there was one waking and one staff sleeping in. We asked where staff slept as we had not seen a designated room. Mrs Jobbins told us that there was a reclining chair in the sitting room. The Expert by Experience told us in their report: A lovely lady [staff member] showed me the home and introduced me to all the residents. She was very respectful to the residents knocked on their doors and explained who I was and that I would be in their home for a few hours. It was evident that the residents loved [the staff member] she seemed to skip from one job to another, giving medication, answering bells and cooked the lunch always smiling. They went on to say [One person] wanted to tell me something but was not able to as the carer was around all the time. Each time she tried to tell me something she had to stop. I think the young carers do not have the empathy with the residents. They will do anything for them but have to be asked and Care Homes for Older People Page 27 of 38 Evidence: do not just chat and reminisce. I found out more in a few hours about different people and the carer had no idea. I asked [one person] about life books she did not think she had one. Mrs Jobbins made all of the staff recruitment records available to us as we requested at the last inspection. Action had been taken to address the requirement we made that open references entitled to whom it may concern must not be accepted as part of the recruitment process. We saw that Mrs Jobbins wrote directly to referees and recorded any telephone conversations if referees did not reply in time. Mrs Jobbins told us she sought advice on employment issues from an agency. We also saw that photographs of staff were on file as required by regulation. We saw that the home was employing three staff who were between 16 and 20 years old. Mrs Jobbins told us that there were two children who were under 16 who came to help with the evening meal. We looked at the homes policy guidance which stated a list of what each age group could do and what they could not do. Mrs Jobbins told us that these people were children who were undertaking work experience and would only be involved in general duties such as some cleaning. She said they were not involved in providing any personal care. There was a risk assessment stating that they could wash knives and use the kettle in the kitchen but were not able to cook. There was a statement that the home and any information about people who use the service must not be discussed outside the home. Action had been taken to address the good practice recommendation we made that the arrangements being made for staff to receive part of their induction before a POVA check is made are documented within the homes policies on recruitment and induction. This is so that there can be no misunderstandings about what a new member of staff is able to do before the POVA check is made. We saw a document which clearly stated that new staff could read policies and procedures and receive training. The document stated that they must have no access to confidential information, must not attend handover or be left alone with people who use the service until all references, POVA or Criminal Records Bureau certificates had been received. We saw that the home had provided staff with information about the new Vetting and Barring Scheme to be introduced in October 2009. We saw that the homes recruitment process was applied to volunteers as well as staff members. There were agreements from parents for those younger people coming to the home. All of the documents and information required by regulation was on file for those staff recently appointed. Mrs Jobbins told us that some of the staff had worked at the home for twenty years and during that time some of the original information may have been archived with their old contracts. She also said that some original Care Homes for Older People Page 28 of 38 Evidence: references had been lost. We saw that Mrs Jobbins had kept a record of every member of staffs Criminal Records Bureau certificate number on file. We looked at staff training. Mrs Jobbins told us she had signed up with Skills for Care and staff had already received some training from them. The staffing policy stated that staff have at least two courses each year for you to update your knowledge and understanding the individual residents needs. There was a document called the staff annual development plan and dated January 2009. In the AQAA Mrs Jobbins told us that over 80 of staff have at least NVQ Level 2. Two of the senior staff held NVQ Level 4. One staff member told us they had nearly completed NVQ Level 3. Another staff told us they had NVQ Level 3 and were undertaking NVQ Level 4. In the AQAA Mrs Jobbins told us about the training undertaken in the last twelve months which included: neurology, dementia, equality and dignity, health and safety, fire regulations safety, nutrition, deprivation of liberty and the Mental Capacity Act 2005. Staff told us that they filled out training workbooks which were externally marked. In staff training files we saw that staff had also undertaken training in care planning and terminology, wound dressing, infection control, palliative care and medication. One of the staff told us about their previous experience in another care home. We saw one staff explain to one person what was happening and what they were going to do next. Staff meetings were held every six months and staff were expected to attend. We asked about staff supervision. We were told that there was no formal supervision but staff were supervised on the job. Mrs Jobbins told us that she observed staff going about their duties, or sat with them and talked about training. She also said she discussed staff members work with them. Care Homes for Older People Page 29 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements ensure good continuity in the day to day running of the home. Mrs Jobbins has started the qualification for registered managers. Quality assurance is being developed. Better recording and auditing systems need to be in place to show good evidence of safely holding any money on peoples behalf. Mrs Jobbins has addressed the majority of the requirements and recommendations we made at previous inspections. However people remain at risk from being locked in bathrooms if they cannot use the lock. People also risk falling from upstairs windows because the restrictors can be overridden. Evidence: Mrs Jobbins has run the home for over twenty years and was originally registered with Wiltshire County Council, when she was considered to meet the standards in respect of supervisory experience, qualifications and competence. She told us about her twenty eight years previous experience as an auxiliary nurse, caring for different age groups in hospitals, residential schools and in peoples own homes. An experienced deputy manager and senior carers take responsibility when Mrs Jobbins is not Care Homes for Older People Page 30 of 38 Evidence: working. Mrs Jobbins showed us her training record with certificates within the last year for: end of life care, neurological disease, NCFE (a national awarding body for vocation courses) Level 2 in understanding prevention of MRSA, managing conflict, causes of aggression, managing stress, risk assessment in care, tissue viability, dementia, equality and diversity and The Mental Capacity Act 2005. Mrs Jobbins told us that she had commenced the Leadership and Management for Care Services Award. She said that two senior staff were also undertaking the award. Mrs Jobbins told us that she had recently undertaken a course on neurology, together with the deputy manager. She told us that the neurology nurse and specialist had input with one person who used the service. Mrs Jobbins told us that she had undertaken a course in deprivation of liberty. The course had been held at the home and relatives invited to join in. Mrs Jobbins was working the waking night shift on the day that we first visited. We ended the inspection so that she could get some rest before working the night and agreed to return on the 11th September 2009 to complete the inspection. We saw that Mrs Jobbins was also working another night that week and one the following week. She told us that she worked the night shifts rather than employ agency staff who people did not know. The Expert by Experience told us: [One person] said Jenny [Mrs Jobbins] is lovely and nothing is too much trouble. In the three hours I was at the home I did not see Jenny interact with any of the residents. There were two staff and Mrs Jobbins when we arrived at the home. One of the senior staff came in to run the shift so that Mrs Jobbins could help us with the inspection. Action had been taken to address the requirement we made that the application to vary the homes category of registration to include dementia must be progressed. Mrs Jobbins application to vary the homes registration to 9 older people including 3 people who may have a dementia, was approved in June 2009. Some action had been taken to address the requirement we made that staff and others must be made aware of our role and powers as regulators. We said that any policies on restricting our access to information and documents must state this. We said that people, their relatives and staff should know that we can examine all documents and information required by regulation. There was a policy about Care Homes for Older People Page 31 of 38 Evidence: inspections and access to information. The policy stated that we do not have automatic rights to access information about people who live at the home. This is untrue. We said that the policy must be further amended to show precisely about our responsibilities in terms of inspection and access to documents required by regulation. Mrs Jobbins made all of the records and documents available to us, as we required at the last inspection. Mrs Jobbins asked each of the people who used the service whether they agreed for us to inspect their records. At the last inspection we had also required that staff and others were made aware of our role as regulators and any policies on restricting our access to information and documents must state this. Mrs Jobbins had produced a policy. It did not mention that it is an offence to obstruct us. During this inspection we were invited to join Mrs Jobbins and staff members for the handover. We asked about supervision. Staff told us they were observed in carrying out different tasks with people who use the service. We asked them whether they had formal supervision, time allocated separately to formally discuss their own agenda, training and the philosophy of care. They told us they did not. There were supervision notes in staff files. Mrs Jobbins told us that she would carry out spot checks on staff performance. Action had been taken to address the requirement that an annual improvement plan must be produced after taking into consideration the views gained from different parties. Mrs Jobbins sent us her action plan following the inspection. She told us that she also met with families every three months. We suggested that staff should also be included in the audit so their views could be taken into account. In the AQAA Mrs Jobbins told us we meet with the residents and their family, friend, representative, advocates at least twice a year. We follow up the annual quality assurance feed back and implement any changes immediately. Records were kept of maintenance checks and repairs. Assessments had been carried out on the Control of Substances Hazardous to Health. There was a fire risk assessment in place. Action had been taken to address the requirement we made that staffs moving and handling of people must be regularly monitored. Mrs Jobbins told us that she made spot checks on staff moving and handling to make sure of continued good practice. We asked whether the home had a hoist. Mrs Jobbins told us that a hoist was not needed as people were able to move themselves. She told us there were slide sheets available but they were not used. The Expert by Experience told us I am not sure Care Homes for Older People Page 32 of 38 Evidence: how one carer got [one person] out of the chair but when I looked up she was holding both her hands taking her to the door. We also saw that some people were being walked by staff holding both their hands and walking backwards. We said that we were concerned about risks to people and to staff. We also saw that some people were very frail and cared for in their bedrooms due to extreme old age. Mrs Jobbins told us that she would ask the physiotherapist to visit and advise on moving people. Mrs Jobbins had addressed the majority of the requirements and recommendations made at previous inspections. Care Homes for Older People Page 33 of 38 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 13 Bathing risk assessments must identify how long people should be left unattended. So that peoples risk of drowning is minimised. 24/02/2009 2 25 13 People must be able to safely 24/02/2009 open the windows to the first floor. So they have safe access to ventilation. 3 38 13 The windows to the first floor 24/02/2009 must have their openings restricted. So that people are not at risk of falling out. Care Homes for Older People Page 34 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Care plans must identify how pressure area care is to be delivered to those people who are assessed as at risk of developing pressure sores. A referral to the policy document is insufficient. So that peoples individual care needs are met and monitored. 30/11/2009 2 18 13 People must never be locked 27/11/2009 alone in bathrooms. So that people are never deprived of their liberty. 3 18 13 There must be clear written guidance about the use of any listening devices. To protect peoples privacy and dignity. 27/11/2009 4 35 17 The records of all transactions for money kept on peoples behalf must 30/11/2009 Care Homes for Older People Page 35 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action show a balance after each transaction. The arrangements must be audited more regularly. So that people know the home keeps their money safely. 5 38 13 Whilst restrictors have been fitted to the upstairs windows, they must be of a kind that cannot be over ridden. So that people are not at risk of springing the catch, opening the window and falling out. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 27/11/2009 1 7 The home should consider whether the practice of putting everyones name in the toileting book is person centred care, particularly for those people who are described as self caring. Whilst a bathing policy showed that no one should be left alone in the bath, care plans and risk assessment should show individual support needs. The arrangements for holding money on peoples behalf should be better documented and more regularly audited. So that mistakes are better traced. Records should be kept of discussions with people as to whether they have made a positive choice to share the double bedrooms. 2 7 3 18 4 23 Care Homes for Older People Page 36 of 38 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 5 38 A hoist should be considered, so that everyones health and safety is safeguarded. Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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