Inspection on 09/07/09 for Leonora

This inspection was carried out on 9th July 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Leonora 12/07/07

Leonora 03/05/06

Leonora 08/12/05

Leonora 08/07/05

Leonora 15/03/05

Leonora 27/09/04

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.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Leonora Wood Lane Chippenham Wiltshire SN15 3DY     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: Alison Duffy     Date: 1 3 0 7 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 38 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Leonora Wood Lane Chippenham Wiltshire SN15 3DY 03003031445 03003031449 chippenham@pilgrimhomes.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Pilgrim Homes care home 21 Number of places (if applicable): Under 65 Over 65 21 21 dementia old age, not falling within any other category Additional conditions: 0 0 When the accommodation identified in the variation application dated 28 June 2004 is no longer required by one or both of the two service users referred to in the same application, occupancy of the home must revert to 20. The Commission must therefore be notified immediately of any changes to occupancy of the identified accommodation. Date of last inspection Brief description of the care home Leonora is operated by Pilgrim Homes, which is a Protestant Christian organisation. People who apply to live at the home must be in full agreement with Pilgrim Homes doctrinal basis. The Registered Manager is Mrs Gaie Marshall. Mrs Marshall has been in post since November 2005. The home is registered to provide care to twenty older people, five of whom may have dementia. The condition of registration stated within this report no longer applies. Leonora is a spacious detached property, which is situated within a residential area of Chippenham. The home also contains a sheltered and very sheltered housing scheme. Peoples bedrooms are located on the ground and first floor. A passenger lift gives level access to all but five bedrooms. These rooms are accessed by a number of small steps. There are two communal lounges and a separate Care Homes for Older People Page 4 of 38 Brief description of the care home dining room. Staffing levels are maintained at three carers and one senior carer on duty until 2pm and one senior carer and two carers throughout the rest of the afternoon and evening. There are also additional housekeeping and catering staff and an administrator and maintenance officer. At night, at present, there are two members of waking staff. An on call management system is also available. The contact details of the service have recently changed. The telephone number of the home is now 0300 303 1445 rather than 01249 651613, as stated within this report. The fax number is 0300 303 1449. The new e mail address is www.pilgrimhomes.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: Before visiting Leonora, 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. Information from the AQAA is detailed within this report. We sent surveys, for people to complete if they wanted to. We also sent the home surveys to be distributed to staff and health care professionals. This enabled us to get peoples views about their experiences of the home. Feedback from surveys is reported upon within this report. We had surveys back from three people who use the service, six staff members and two health care professionals. We looked at all the information that we have received about the home since the last Care Homes for Older People Page 6 of 38 inspection. This helped us to decide what we should focus on during an unannounced visit to the home. This visit took place on the 9th July 2009 between 9.40am and 4.50pm and on the 13th July between 1.50pm and 6.40pm. Mrs Marshall was available throughout our visit and received feedback at the end. During our visit, we met with people who use the service within communal areas and in private, in their bedrooms. We spoke to staff members on duty. We toured the accommodation and saw people having lunch. We looked at care-planning information, staff training records and recruitment documentation. We also looked at documentation in relation to health and safety, complaints and quality assurance. The previous inspection of Leonora took place on the 12th July 2007. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. 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 experiences of people using the service. What the care home does well: What has improved since the last inspection? What they could do better: Alternative ways to manage some peoples continence must be implemented as the current system is potentially damaging to peoples skin. The system also compromises peoples dignity. Care plans must be updated as peoples needs change. The plans must be sufficiently detailed to reflect peoples needs and the support they require. Any wound must be identified within the persons care plan. There must also be details of any intervention required by the staff team to promote healing with specific guidance from the district nurse who is responsible for managing the wound. Any potential risk to the individual must be identified. Measures to minimise the risk Care Homes for Older People Page 8 of 38 must be put in place and be regularly reviewed. Medication must be administered, according to the prescription. Staff must sign the medication administration record when administering medication to people. In the event of a medication error, the home must let us know without delay and a regulation 37 notification must be completed and sent to us. The refurbishment of the kitchen must be given urgent priority and not be rescheduled due to other financial commitments. A review of staffing levels in terms of the current dependency of people and the impact upon people to make choices in their every day lives must be undertaken. While staff have access to a range of training, consideration should be given to involving specialised trainers, rather than completing all training in house. A review of the training should be undertaken to ensure the length of each session is sufficient to give staff adequate knowledge. Further clarification should be gained from specialised health care professionals regarding the use of the hoist. In the meantime, two staff should undertake the procedure to minimise the risk of an accident. 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.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. People benefit from a clear, well organised admission process, which ensures their needs will be met within the home. Evidence: At the last inspection, we saw that if a person wished to consider moving into the home, they would need to formally apply. They would need to share the beliefs of the Protestant Christian Church before their application was considered. Following this, the manager would undertake an assessment to ensure the home could meet the persons needs. People could stay at the home for a short while so that they could see what the home was like. After moving in, people had a period of time whereby they could finally be assured that Leonora was the right place for them. Mrs Marshall told us that there had been no changes to the assessment process since the last inspection. The AQAA confirmed this stating we have a comprehensive Applications and Admissions Policy, which ensures the prospective service users are made aware of what the home has to Care Homes for Older People Page 11 of 38 Evidence: offer. Full care needs assessment of service user (including those who are local authority funded) prior to admission - in their own home or in hospital if that is where they are - to ensure the home can meet their needs: also to build relationship to be able to communicate care needs to staff. People told us that they had chosen Leonora, as it was a Christian Home. One person said I knew I needed a Christian Home to be happy. It was just a case of where it would be. Another person told us I knew I would be happy here. It is a Christian Home so I knew this was the right place for me. Another person said I knew the home very well before moving here. I did try other Pilgrim Homes but chose this one due to the area. Being here enables my friends to visit regularly. I can also continue to visit my local church. Within surveys, people told us that they received sufficient information about the home before moving in. We looked at the assessment documentation of one person who had recently moved into the home. The information was clearly written and identified the persons basic care needs. Many questions were in the format of tick style answers yet additional information was also recorded. As a means to improve the service over the next twelve months, the AQAA stated continue to improve communication so home prepared for new admissions and transition goes well. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied with their care yet potential risks and how they are to be managed must be clearly identified to ensure wellbeing. People have good access to health care intervention. Medication systems are generally well managed yet greater attention to clear recording would reduce the risk of error. Peoples privacy and dignity is respected yet systems to manage continence need investigation. Evidence: Within surveys, people told us that they always received the care and support they needed. In relation to what the home does well, one person told us everything, all is done in every way for us, the residents. A lovely Christian home for us, in the evening of our years. Care, kindness and love all found at Leonora. Within their survey, a health care professional told us Leonora Home provides a caring environment for residents. Privacy and dignity are promoted when caring for residents. Another health care professional said very caring home. At the last inspection, we made a requirement to ensure that care plans must stipulate Care Homes for Older People Page 13 of 38 Evidence: the support people needed, in order for staff to meet both long and short-term care needs. We saw that this had been met in part. One care plan showed good detail regarding the support the person needed with a shower or a bath and to maintain healthy skin. A list of topical creams and where they were to be applied was stated. There was a clear record of the persons weight. The plan stated that the person had good and bad days. There was no further clarity, as to what these terms meant. A mobility assessment showed that the person needed to use a zimmer frame. The plan of action stated to ensure XX uses his/her frame, at all times. It was not clear how staff were to ensure this. The eating and drinking plan showed that the person had their food liquidised. The person told us that they were now trying to eat their food by cutting it up into small pieces. Even though the plan had recently been evaluated, this conflict of information remained. Mrs Marshall told us that the persons good and bad days reflected whether their food was cut up or liquidised. There was a clear assessment about a persons continence although the plan of care was unclear. The plan stated to support XX with managing his/her urinary problems and to support XX to manage his/her bowel actions. Further information did not indicate what this meant in practice. As a means to encourage hydration staff ensured people had fresh drinking water in their rooms every day. We saw staff deliver the drinking water to peoples bedrooms. We saw that one person was to be supported by two members of staff when needing assistance at night. This had been the advice of a physiotherapist. The persons care plan stated one or two carers to mobilise. The care plan summary did not mention the need for two staff at night. The accident record showed that the person had a high level of falls yet there was no specific falls risk assessment in place. A manual handling assessment identified the need for one or two staff depending on the task to be undertaken. There was no information about how the persons poor sight impacted upon their mobility. We saw that a swallowing assessment highlighted the risk of choking. There was no risk assessment in place regarding this. We saw within another care plan that a person had lost weight. There was not a care plan in place to minimise further weight loss. The persons care plan did not state the persons general deterioration in health, as described to us by staff. We saw that the persons manual handling assessment stated the need for one or two carers to assist with mobility yet the risk assessment stated always walk with a zimmer, if unsteady, walk with her/him. We saw within daily records that the person was in a lot of pain. There was no information about how the person was supported to manage this. Care Homes for Older People Page 14 of 38 Evidence: We saw that staff had recorded general aspects of well being within daily records. The records were factual and did not contain subjective language, as at the last inspection. Within the records it was evident that two people were described as being very wet in the morning through incontinence during the night. Staff confirmed this, stating that they aimed to support these people first, to ensure they got out of their wet nightwear. We asked staff when people were supported to the toilet in the night. They said that due to only working in the day time, they were not aware of actual times. We asked Mrs Marshall, as we were concerned about people being in wet clothing. She said people had had their continence needs assessed by a continence advisor. They had been allocated incontinence pads based on an allocation of one pad a night. Mrs Marshall said the allowance was insufficient and therefore people were often in wet clothing by the morning. We were concerned about the impact of this on a persons skin and their lack of dignity. We said that further interventions must be investigated to ensure the persons well being. We saw that one person had been assessed as being at risk of developing a pressure sore. There was good detail on the persons care plan about the use of various topical creams. Pressure relieving equipment such as specialised cushions and a mattress was also stated. There was no information about supporting the person to change their position during the day or night. The daily records identified that the person was often awake at night yet there was no evidence of assistance given. Within daily records we saw that the person had two sore areas. There was no follow up information about this. The sores and their management were not identified on the persons care plan. The care plan stated that they needed to be toileted regularly. There was no clarity of the frequency that the person needed to be supported. The person did not have a care plan regarding eating and drinking, despite needing full assistance for both tasks. We saw that there were general risk assessments in place in relation to aspects such as walking, the use of the stairs and using a wheelchair. The assessments did not identify the specific risks to individuals or how they were to be managed. The risks were generally stated as could fall. Risk assessments relating to the newest person to the home, had not been completed. Within their survey, a health care professional told us Leonora staff always contact us promptly and appropriately regarding nursing care required for residents. I feel the district nurse team have an excellent working relationship with the care staff and residents at the home. A clear record of all health care interventions was maintained. The record included visits from the GP, district nurse, optician and chiropodist. We saw that people had received specialist services in relation to their individual health care conditions. One Care Homes for Older People Page 15 of 38 Evidence: person was given exercises after an appointment with a speech and language assessment. However, there was no information to evidence that the person had been supported to do the exercises. Mrs Marshall told us that the person did not find the exercises easy and did not want to do them. There was no information to state that the speech and language therapist had been informed of this. Within another speech and language assessment, the persons ability to take their medication was to be monitored. There was no evidence of this within the persons care plan. We saw within one care plan that there was a letter from a GP. It stated that the person must not be resuscitated due to their quality of life. There was no further information, as to how this decision had been made. Mrs Marshall told us that she believed the GP had spoken to the persons family. We advised that an independent advocate be involved to ensure the persons best interests. The medication was stored securely and had been satisfactorily receipted when it arrived into the home. As good practice, we saw that items with a short shelf life, such as eye drops, had been dated when opened. Policies and procedures were readily available for staff reference at the beginning of the medication record. Staff had received training in the safe handling of medication and were receiving a refresher session during our inspection. A monitored dosage system was in place to administer medication to people. There was a list of homely remedies, which had been signed by a GP. This had recently been updated. We saw that staff had generally signed the medication administration record when administering medication to people. However, not all topical creams had been signed for and one person had four gaps within their administration record. We saw that the medication had been removed from the monitored dosage system. From this, it appeared that the person had taken the medication yet staff had not signed to demonstrate they had given it. Following the inspection, Mrs Margetts, Housing and Care Services manager told us that charts to show the application of topical creams were kept in peoples rooms. We advised that the medication administration record should show this. We saw that two people were prescribed a topical cream, whereby the instructions on the records stated use as directed. There was no other information about their use. Another record showed the use of eye drops, when required. There was no evidence that the person had used these. There were no details about them on the persons care plan. Another person was prescribed an eye lid solution. There were no details within the persons care plan, as to how this was to be used. We saw that one medication was prescribed to be taken once a day. On one day, there were two staff signatures, suggesting it had been taken twice. We saw that one medication had been Care Homes for Older People Page 16 of 38 Evidence: changed by a GP yet the instruction had not been signed or dated. There were three other instructions that had been handwritten. We advised that any hand written instruction be signed, dated and countersigned by another member of staff. We saw that one person was taking two different types of pain relief. One was to be taken three times a day yet there were no signatures to show it had been administered to the person. The other was to be taken as required. We advised that the maximum dose be stated. Within the notes of a care staff meeting, we saw that it was decided, we would not be informed of a medication error unless medical intervention was needed. As a GP must be called after any medication error, we said this constitutes medical intervention. Any medication error must therefore be reported to us under regulation 37. We saw that staff consistently knocked on peoples bedroom doors and awaited a reply before entering. All staff approached people in a kindly, understanding manner. We saw that people were called by their preferred names. Only one person raised concern about how privacy and dignity were maintained. They said I dont like the fact that we have men here, as residents. Its not nice, as they dont always use the locks or turn the engaged signs on the doors of the toilets. You walk in to use the toilet yourself but dont expect to find someone half dressed in there. Its very embarrassing. 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 are able to join in with a number of social activities and have visitors as they wish. Some people may benefit from going out into the community on a more regular basis. Staffing levels are impacting on peoples choices and therefore need to be monitored. People enjoy the range of meals available yet the use of convenience foods should be monitored to ensure a good nutritional intake. Evidence: People told us that they were generally content to spend time in their room or in one of the communal lounges. One person said its nice that we are allowed to come and go as we wish. Another person said Im lucky, as I am happy with my own company. I have lots of things to do, which keep me occupied. I also have lots of visitors, which is lovely. Other comments included I join in with the art club and like the reading group where staff read to us, I like the sit and be fit, we have regular devotions that I enjoy and we have a number of speakers who are all very good. One person told us there used to be lots of things going on but its different now. There are lots of people who cant hear or cant communicate well, so its difficult to find things people can do. Another person had a similar view. They said its really difficult to hold a conversation with people now. Everyone here seems so much frailer than before. We discussed this Care Homes for Older People Page 18 of 38 Evidence: with Mrs Marshall during feedback. She agreed that people were frailer than before but she did not see this as a barrier for people to develop relationships. She said that people often sit together for a chat after lunch. Within the AQAA, it stated we try as far as possible to enable service users to live ordinary lives by providing plenty for social contact within the home. Some go out to church/meetings or with family. Service users choose whether or not to attend activities. One person told us that they regularly go out with family and friends. They said I love the home but I also like going out to see whats going on around us. It does me good to get out. Another person told us you can only go out regularly if you have someone to take you. If you have family, its easier, yet saying that, Im too old for all that now. I need a quiet life. Another person told us they did take me out in a wheelchair to town a while ago but I havent been out recently. Im quite happy here with my thoughts. I dont feel alone. Mrs Marshall told us that people do go out on a regular basis, if they want to. Some people regularly go to church and there had recently been a celebration of the home. A trip to a church members home for tea was planned. Within the AQAA, we saw that a team of Home Visitors regularly visited the home and spent time talking with people. The AQAA also stated that Mrs Marshall was looking to recruit volunteers to help with social activity provision. Within our visit, we saw that some people joined in with the art group. One person told us that the teacher often brought things in for people to draw. They said it can be as serious, as you want it to be, but Im not very good so to me, its a bit of fun. We saw that a service also took place, during our visit. We heard that people participated well although we did not join in with the service. Within surveys, two people told us that there were usually activities provided, which they could join in with. One person said there were always activities available. People told us that they were able to follow their own routines, if they were physically able to do so. Three people told us, they could get up and go to bed when they wanted to. One person said the staff are very good. They bring me drinks and my meals so I dont have to go down to the dining room. Another person said you can choose when you want to go to bed, but if you need help you need to wait your turn. I usually go early so that I can be in bed before it starts to get busy. By doing that, I dont have to wait. Doing that makes me and the staff happy. One member of staff told us that sometimes people do need to wait to receive their personal care. They said the mornings are very busy and we have asked some people, who dont mind, to have their bath in the evening. It just enables us to give people a bit more time rather than Care Homes for Older People Page 19 of 38 Evidence: rushing. We asked Mrs Marshall about how peoples choices were promoted in relation to existing staffing levels. Mrs Marshall told us that generally people receive their care at a time of their choice. However, she said there were times when people could be asked to wait, as not everyone could be put to bed at the same time. It would not be possible even if you had increased staffing. Staffing levels are discussed later within this report. People were complimentary about the meals provided. Specific comments included the food is always very good and well cooked, I enjoy my food very much, its always of a good standard and its not food, its a feast. We saw that lunch was pork casserole with mushrooms, spinach and saute potatoes. Dessert was apricot crumble and custard. The food was served in serving dishes so that people could help themselves to the amounts they wanted. We looked at the menu and saw that the main meal of the day consisted of traditional foods such as roast lamb, liver and onions, sausage hot pot and cottage pie. The menu showed an alternative, which Mrs Marshall said people rarely had. Some alternatives were shown as turkey meatballs, beef burgers and chicken nuggets. We saw that such items were also included on the teatime menu. We advised Mrs Marshall to monitor the use of these foods. We said that if regularly used, the nutritional content of the items should be assessed. Staff told us that three people needed staff support to eat. During the evening meal, we saw a staff member standing up to support a person to eat. Mrs Marshall told us that she felt there was a reason for this, as staff all know that they need to sit with people, whilst giving assistance. One staff member told us that due to the number of staff on duty, a staff member may encourage a person to eat, whilst supporting another person to eat. They said it was not always easy to give people undisturbed, individual attention due to peoples complex needs. With surveys, two people told us that they always liked the meals. One person said they usually did. Care Homes for Older People Page 20 of 38 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to make a complaint and feel that any issue would be quickly resolved. Clear arrangements are in place to help ensure people are protected from harm. Evidence: People told us that they knew how to make a complaint if they were not happy. They said they would discuss the issue with a member of staff or with Gaie [the manager.] People confirmed that they knew how to make a complaint within their survey. Staff also told us, within their survey, that they knew what to do if a person had concerns about the home. One member of staff told us that they would immediately inform Gaie [the manager] if there was any form of problem. They said they would try to deal with the issue but felt the manager would ultimately address the situation. A domestic staff told us we spend a lot of time in the rooms with people. They generally open up and tell us if they have a problem. We can then inform someone to sort things out. Sometimes people are just happy to tell someone and off load. The AQAA stated, in terms of what the home does well, display complaints procedure on notice board. Manager and staff encourage residents and visitors to talk about any issues that they may have effecting the service users safety or quality of life. Keep Care Homes for Older People Page 21 of 38 Evidence: channels of communication open by talking to service user/family if issues arise. Mrs Marshall told us that there had not been any formal complaints since the last inspection. There were no entries within the complaint log. Mrs Marshall told us that any day-to-day concerns or suggestions, were immediately addressed if at all possible, yet not recorded. We advised that any issues be documented, to show how the home managed concerns. Mrs Marshall told us that she was reluctant to increase the amount of paperwork in place although could see the reason for the documentation. We have not received any formal complaints about the service since the last inspection. Staff told us that they received regular training in adult abuse. We saw from the training records that Mrs Marshall did the majority of this training. She said that she used DVDs and questionnaires. At the last inspection, we recommended that consideration be given to the local Safeguarding Adult Unit facilitating a training session on local adult protection reporting procedures. Mrs Margetts told us that Mrs Marshall had contacted the Safeguarding Adults Unit yet did not feel what the unit had to offer, would benefit the staff team. Mrs Marshall told us that all staff continued to be given a copy of No Secrets, which details Wiltshire and Swindons safeguarding reporting protocols. One member of staff told us that they had a copy of the procedure, which they could refer to at any time. There was also a copy displayed on the notice board in the office. Mrs Marshall told us that she had completed the local councils training in Safeguarding Vulnerable people. The content of the training was then cascaded to staff within an in house training session. At the last inspection, we recommended that any allegation of abuse be discussed with the local social work team and be referred to the Safeguarding Adults Unit. We saw that this had been addressed. Care Homes for Older People Page 22 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good 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 clean, comfortable, well-maintained environment, which is homely in style. Evidence: Peoples bedrooms were located on the ground and first floor. A passenger lift provided level access to all but five bedrooms. These rooms were accessed by a number of steps. We saw that peoples rooms were personalised with various pictures, ornaments and other personal possessions. Many had their own furniture. One person told us that they had their own telephone. They said its such a lifeline, as I can talk to my family and friends whenever I wish. They can also ring me, which is lovely. People told us that they had a call bell within easy reach. One person said its over there but I dont use it. Another person said yes, its there. I use it if I need to. Other comments about the use of the call bell system are detailed later in this report. We saw that one bedroom was being refurbished. The outside paintwork was also being redecorated. The AQAA stated that the carpet had been replaced in one of the lounges. As a means to improve the service over the next twelve months, the AQAA stated continue to refurbish rooms, as become vacant, refurbishment of kitchen, painting of outside of building. Care Homes for Older People Page 23 of 38 Evidence: We saw that radiators within peoples bedrooms had been covered to minimise the risk of people burning themselves if they were to fall against them. We saw a radiator within a bathroom that was not covered. The hot water pipes had been covered. Windows on the first floor had been fitted with restrictors. We saw that a number of windows appeared to open wider than expected with restrictors fitted. Mrs Marshall told us that the maintenance person had recently checked the restrictors and no problems had been reported. She said she would re visit this with the maintenance person. There were two comfortable communal lounges and a separate dining room. There were bathrooms with assisted baths and a walk in shower. Staff told us that one hoist had broken and could not be repaired. They said people currently used the other bathroom, further down the corridor. Mrs Marshall told us that the hoist would be replaced yet people used other bathrooms, through choice. She said people do not specifically rely on that bathroom. Some people choose to go downstairs, to use the bathroom of their choice. We saw that the home was clean and there were no unpleasant odours. A domestic staff told us that they were responsible for cleaning the bedrooms, bathrooms and toilets on either floor. They said there is a lot to do but we have a good routine, so everything gets done. They said that some people choose to help dust their own room. We saw that one bathroom would benefit from some refurbishment. The seal between the bath and the wall tiles was in need of replacement. There was also tape on the arms of the toilet frame, which made the arms difficult to keep clean. At the last and previous inspections, we were told that the kitchen was due to be refurbished. The AQAA stated that the refurbishment had been delayed. The cook confirmed this. They said hopefully it will be done later this year or early next year. Everyone knows it needs doing but it keeps getting put back because of other priorities. We saw that the kitchen was in desperate need of refurbishment. The paint on the wall and the ceiling was flaking. There were cracked tiles, some of which had been covered with tape. The window sill was broken and the cupboards were ill fitting. The cupboards and the flooring were difficult to keep clean due to staining and their age. We saw that an external Health and Safety Audit, had identified the need to give priority to the planned refurbishment. Mrs Marshall told us that the refurbishment continued to be planned and should take place in the near future. We said that we were concerned that we had heard this at our last inspection yet no progress had been made. Mrs Marshall told us that she would raise the urgency with senior management. There was an additional kitchen whereby the washing up of peoples crockery was undertaken. Visitors were able to make their own refreshments in this room. We saw that this area was tidy and well maintained. Care Homes for Older People Page 24 of 38 Evidence: The laundry was ordered and clean. During the afternoon, we saw that peoples clothing had been laundered and returned to them. There were no items, which appeared unclaimed within the laundry area. Within surveys, people told us that the home was always fresh and clean. We saw that staff had good access to disposable protective clothing. Care Homes for Older People Page 25 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current staffing levels are impacting upon the choices people have in their every day lives. People are protected through a robust recruitment procedure. While staff training is given priority, additional knowledge would be gained through the use of specialised trainers. Evidence: Staff told us that in the morning and early afternoon, there were generally three care staff and a senior carer on duty. There were also two domestics and a cook, a maintenance person and an administrator. During the late afternoon and evening there were two carers and a senior carer. On three evenings a week, staff told us there was a domestic who assisted with the evening meal and the washing up. On days when the domestic was not on duty, the care staff did these tasks. Care staff prepared the evening meal, each day. We asked staff within their surveys if there were enough staff to meet the individual needs of all the people who use the service. One staff said usually, four said sometimes and one staff said never. We saw that there were a number of people with complex care needs. Staff told us that approximately twelve people required staff assistance to maintain their personal care needs on a daily basis. Four of these required the support of two staff members for all care tasks and transfers. Three Care Homes for Older People Page 26 of 38 Evidence: people required the assistance of staff to eat. Staff told us that they generally worked in close proximity of each other, when supporting people who needed more care. This meant that if they needed additional help with a person, they could call on someone quickly. One staff member told us that there was limited time to talk to people unless supporting them with personal care routines. They said time is a challenge but we do our best for people. We get there and always make sure that people have what they want. Another staff member said sometimes its a rush to get everything done but we try to keep things relaxed. The busiest time is between seven and ten in the morning. Another staff member said we have a lot of people here who need a lot of care. People are now much frailer than before but unfortunately our staffing levels havent been increased to accommodate the extra. We still get the same number of staff even though peoples needs are so much more. We saw within a daily record that a member of staff had recorded late getting XX up. I said sorry as I was very busy. During our visit, we saw two staff having their break in the dining room. A senior carer asked them if they could be given supervision. The staff asked why and what the session would be about. Staff were told that it was a government directive and the subject was nutrition. The care leader said if you dont mind doing it in your break that would be good, as we wont get time otherwise. The staff agreed to this and discussion was held. Mrs Marshall told us that that staffing levels at night had recently been increased, as one person requires further support due to the risk of falling. Due to this there were now two waking night staff rather than one waking and one sleeping in member of staff. In terms of staffing levels and the dependency of peoples needs, Mrs Marshall told us it seems that it is all due to the home now being full. The staff are busier, as we have more people yet they are not as busy as they have been. We are working to our staffing allocation and have been much busier. Being at full occupancy has made a difference but we are not over busy. Mrs Marshall told us that consideration had been given to routines, so that staff could concentrate further on care. They said a domestic staff now serves drinks in the morning. People had been told that priority was to be given to care rather than other tasks such as making beds. One person told us about this. They said I dont need any help getting dressed but there was a problem with my bed. There were times when it didnt get made until late morning. I didnt like that, as I often had visitors and it looked untidy. I did speak to the staff and they do it for me now, as early as they can. Mrs Marshall told us staff know they dont need to get everything done before the end of their shift, as the night staff can carry on with what is not done. Care Homes for Older People Page 27 of 38 Evidence: Following the inspection, Mrs Margetts, regional services manager told us the home has more staff now than it ever had, as there are two waking night staff. Im sure each establishment would like more staff but economically, it isnt practicable. Our staffing levels are regularly reviewed and in line with peoples needs. We saw that staff interacted well with people. They were polite, friendly and respectful in their interactions. In response to a persons request for assistance or an answer to a question, we heard staff make comments such as youre welcome and its a pleasure. People were very complimentary about the staff. One person said they are all lovely and they are very skilled. They have regular training I think, which keeps them up to date. Another person said they are very polite and so patient. Each person we spoke to commented about how hard the staff work. They said that staff were very busy. One person told us people are now much more dependent and therefore staff spend much more time with those people who need more time. It takes the staff ages to do the simplest of task with some people. Another person said the staff are lovely but there is only time for an occasional chat. Further comments included they have a lot on their plate. They are very busy but so patient and they have their work cut out with some people here. Its not like it used to be. Some people need such a lot of care. Its difficult for the staff to get around to everyone. We talked to some people about the use of their call bell. One person said you can ring it, as that is what it is there for, but I try not to. Another person said I use my bell if I need to. There are varying times that you have to wait before someone comes, as the staff are so busy with everyone else. Another person said it depends on what time you ring your bell, as to what sort of time you need to wait for a response. We saw that staffing levels had been discussed at recent resident meetings. Within a copy of the minutes of one meeting, it was stated Bells - it is always appreciated when residents are patient when they need assistance. If your bell is not answered straight away, it is because staff may be busy with another resident who can not be left alone until they are in a safe position. We spoke to staff about this. They said that they try to immediately answer all call bells, as someone could have fallen. They said they then might need to tell the person that they will return, as soon as possible. One staff member said the majority of people are obviously ok with this, but some get a little upset about having to wait. We do our best to keep people happy. The AQAA stated that recruitment was an area the home did well. It stated stringent recruitment policy and practice for staff and volunteers. We looked at two staff recruitment files. They contained an application form and two written references. We saw that a POVAFirst [Protection of Vulnerable Adults] and a CRB [Criminal Record Bureau] check had been completed before the staff member commenced employment. This showed they were suitable to work with vulnerable people. Within surveys, staff confirmed that the home Care Homes for Older People Page 28 of 38 Evidence: carried out checks, such as CRBs and references, before they started work. Within surveys, staff said that they had training relevant to their role. They said it helped them understand the needs of people. Within discussion, staff told us that they had access to a wide range of training. They said they had recently completed training in manual handling, fire safety, infection control and nutrition. A domestic staff told us they had undertaken manual handling, health and safety, control of substances hazardous to health (COSHH) and fire safety training. We saw that care staff completed medication administration training during our inspection. Within surveys, two staff members told us that training and working as a team, were things the home did well. Another staff member said good atmosphere. Good understanding staff. The AQAA stated that more than 50 per cent of the care staff have National Vocational Qualification. Others have or are working towards level 3. Within their surveys, two health care professionals told us that managers and staff have the right skills to support peoples social and health care needs. We looked at a sample of staff training records. We saw that training in challenging behaviour, manual handling, health and safety, the use of the hoist and fire safety had been undertaken. There had also been training in abuse awareness, therapeutic activity, person centred communication and dementia. We saw that many of the sessions took place over an hour to a two hour period. Mrs Marshall had undertaken many of the sessions. Mrs Margetts had undertaken others. A dietician, a hospice nurse and a practice nurse had undertaken training sessions within the last year. As stated earlier in this report, Mrs Marshall told us that she uses DVDs, questionnaires and discussion to ensure variety. While acknowledging the regularity of training taking place, we suggested that more external facilitators be used to ensure specialist knowledge. We also advised that further time be allocated to topics in order for more depth of knowledge to be achieved. 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. People benefit from a manager who is qualified, experienced and person centred. People are actively encouraged to give their views about the service they receive, as a means to enable improvement. People are safeguarded from harm through clear, well managed health and safety systems. Evidence: Mrs Marshall has been the manager of the home since November 2005. She is a registered nurse and has the Registered Managers Award. Mrs Marshall told us that she also undertakes short training courses and conferences run by the organisation, so she is up to date with current practice. One person told us the home is very well organised. Gaie [the manager] is often around so we can talk about anything with her when we want to. Another person said we have regular meetings so we have every opportunity to give our views and make suggestions. Documentation showed that regular residents meetings were held. We Care Homes for Older People Page 30 of 38 Evidence: saw that the majority of people attended and contributed their views. The home has an established quality assurance system in place. The system involves a range of performance indicators, which are linked to the National Minimum Standards. A section of the system is completed monthly. Key points and how they have been addressed are documented within a Quality Action Point Chart. People using the service and their relatives have the opportunity of completing questionnaires, as part of the system. This enables their views to direct future developments of the service. We saw a summary containing percentages of the findings from the questionnaires people completed. The lowest score was that of support in spiritual life. Mrs Marshall had discussed this within a residents meeting. She said that as the home was already undertaking devotions, services, bible study and prayer meetings, she was not sure what else was wanted. Mrs Marshall told us that she had asked people to give the area thought yet had not received any specific responses. The next lowest area shown from questionnaires was sense of community. Mrs Marshall told us that this was also discussed within a meeting. She said that people were reminded that they could meet up with each other or join in with the organised activities in place. A number of people had placed small amounts of their personal monies, for the home to hold safely. We looked at the systems for managing this. We saw that the system was clear and ordered. Two members of staff had signed to demonstrate each transaction and receipts were in place. The administrator told us that the system was checked on a monthly basis. People and/or their families/representatives were given a copy of the balance sheet on a regular basis. This was to ensure that the risk of financial abuse was minimised. We looked at a number of systems used to ensure peoples health and safety. We saw that a large number of health and safety policies and environmental risk assessments were in place. All had been regularly reviewed. We saw that an inset had been fitted to the low sink in the kitchen, as a risk to staffs backs had been identified. The fire log book demonstrated satisfactory testing and servicing of the fire safety systems. Temperature checks of the hot water systems and tests for legionella had been undertaken. We saw within the AQAA that the maintenance person was due to undertake training in minimising the risk of legionella. Documentation showed that portable electrical appliances had been checked for their safety. A record of all accidents was maintained and monitored. Measures to minimise the risk of further occurrences were evident. Staff told us that there were four people who were unable to stand and therefore needed to use the hoist to transfer. Staff said that they sometimes used the hoist on their own rather than with another staff member. Mrs Marshall told us that manual Care Homes for Older People Page 31 of 38 Evidence: handling guidance they had seen, stated that one person could operate the hoist as long as they were competent and had been satisfactorily trained. Mrs Marshall had developed a risk assessment regarding each staff members competence. She said the practice was not introduced because of current staffing levels. We advised against this practice and would recommend, unless agreed by an external specialist trainer, that two staff members used the hoist at all times. The cook told us that they were fully responsible for the safe systems within the kitchen. We saw that systems such as maintaining fridge and freezer temperatures and taking the temperatures of food before serving were fully documented. Care Homes for Older People Page 32 of 38 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must stipulate the 30/09/2007 support people need, in order for staff to meet both long and short-term care needs. Care Homes for Older People Page 33 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 27 18 A review of staffing levels must be undertaken to ensure they are sufficient to meet peoples individual needs and do not compromise peoples ability to exercise their choice. So that peoples needs are met and they are not at risk of harm. 31/08/2009 2 7 13 Adequate measures must be 31/08/2009 put in place and documented to minimise any potential risk identified. To safeguard people from harm. 3 7 12 Any wound and the intervention required by staff to promote the healing process, must be identified in the persons care plan. To ensure that appropriate intervention is provided to promote the healing process. 31/08/2009 Care Homes for Older People Page 34 of 38 4 7 12 Care plans must fully reflect peoples needs and be up dated, as peoples needs change. So that staff have the required information to support people effectively. 30/09/2009 5 8 12 Alternative systems to 31/08/2009 satisfactorily manage a persons continence must be implemented to ensure the persons wellbeing. So that a persons skin is not at risk and their dignity is maintained. 6 9 13 Staff must ensure that they 31/08/2009 administer all medication, as identified on the prescription. So that people receive their medication as required to maintain their wellbeing. 7 9 37 Any incident, which affects a 31/08/2009 persons wellbeing, including a medication error must be reported to the Commission. So that an additional safeguard is in place to ensure peoples wellbeing. 8 9 13 Staff must ensure that they sign to evidence they have administered medication or have applied a prescribed topical cream. So that people receive their medication without the potential of error. 31/08/2009 Care Homes for Older People Page 35 of 38 9 19 13 Proposals that identify the 31/08/2009 timescales of the refurbishment of the kitchen must be agreed and forwarded to the Commission. So that people are not at risk of contamination due to the poor state of the kitchen facilities. 10 26 13 The seal in the identified bathroom must be replaced. To minimise the risk of infection. 31/08/2009 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 30 Training sessions should be covered in sufficient depth to ensure staff have adequate knowledge about the topic covered. More external trainers with specialised knowledge should be used to enhance the staff training plan and provide staff with additional knowledge to aid their competence. Terms such as regularly should be clarified to provide specific, measurable information. The maximum dose of a medication prescribed as required should be clearly stated. Staff should ask the GP to provide detailed medication instructions rather than print use as directed on labels. All medication and its instruction for use, should be detailed within the persons care plan. Consideration should be given to how social activity provision both in house and within the wider community could be improved upon in terms of peoples individual interests. Staff should ensure that they sit with a person and give 2 30 3 4 5 6 7 7 9 9 9 12 8 15 Care Homes for Older People Page 36 of 38 them uninterrupted time, when assisting them to eat. 9 10 11 15 16 38 The use of convenience foods should be monitored to ensure peoples diet is well balanced and nutritional. A record of concerns, which are addressed on a day-to-day basis should be maintained. Further clarification should be gained from specialised health care professionals regarding the use of the hoist. In the meantime, two staff should undertake the procedure to minimise the risk of an accident. Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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