Inspection on 29/08/08 for Malmesbury House

This inspection was carried out on 29th August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Malmesbury House 25/08/09

Malmesbury House 30/08/07

Malmesbury House 15/05/06

Malmesbury House 02/11/05

Malmesbury House 18/04/05

Malmesbury House 11/01/05

Malmesbury House 20/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Malmesbury House Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA     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: Patricia Collins     Date: 0 5 0 9 2 0 0 8 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. the things that people have said are important to them: They reflect 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 © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Malmesbury House 18 Beauchamp Road Malmesbury House East Molesey Surrey KT8 0PA 02087830444 Telephone number: Fax number: Email address: Provider web address: mail@gajraj1.freeserve.co.uk Name of registered provider(s): Name of registered manager (if applicable) Mrs Mary Gajraj,Dr H Gajraj,Dr N Gajraj Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability sensory impairment Additional conditions: Of the fourteen (14) service users in category DE(E) (Dementia - over 65 years of age), one (1) named person may also fall within category SI(E) (Sens Of the fourteen (14) service users in category DE(E) (Dementia - over 65 years of age), one (1) named person may also fall within category SI(E) (Sensory Impairment - over 65 years of age). Date of last inspection Care Homes for Older People Page 4 of 38 Over 65 14 2 2 1 1 0 0 0 0 0 Brief description of the care home Malmsbury House is a care home providing personal care and accommodation for up to 19 older people, the majority of whom have dementia as their primary condition. The building is a large detached property situated in a quiet residential area. The community amenities and shops of West Molesey are conveniently nearby. The accommodation is arranged on three floors, accessible by a passenger lift. Most bedrooms are of a good size and are single occupancy and have en suite facilities. Some of the ground floor bedrooms have doors leading to the enclosed garden and others have balconies. The home is set in spacious, well-maintained grounds and provision includes a furnished courtyard. There is a spacious, well furnished conservatory and suitable bathing and toilet facilities. A car park is provided at the front of the premises. 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: Date of last key inspection : 30th August 2007 Weekly fee charges range between 600 pounds and 650 pounds. This unannounced inspection forms part of the key inspection process using the Inspecting for Better Lives (IBL) methodology. The inspections visits were carried out by one inspector over two days and a total of fourteen hours was spent at the home. The report will say what we found as it is written on behalf of the Commission for Social Care Inspection (CSCI). We have taken account of all available information to inform judgements about how Care Homes for Older People Page 6 of 38 well the home is meeting the national minimum standards for older people. This includes the accumulative assessment, knowledge and experience of the home since its last key inspection. Also the findings of an unannounced random inspection carried out in November 2007. Copies of that inspection report are available to the public on request. The inspection process for this inspection incorporated discussions with the home manager and telephone contact with the providers representative. We also considered the providers written response to an immediate requirement made at the time of the second visit. We sampled records and toured the building and the garden and spoke with six staff and three visitors. We have also considered all the information received in surveys completed by two relatives, a person using the homes services, from three employees and the home manager. We took into account the content of the homes Annual Quality Assurance Assessment (AQAA). This is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information and an up-to date picture of the current situation at the home. During the course of the inspection visits we spoke with most of the people using services to establish their views about the home and their care. Not all of the people using services, who mostly have dementia, were able to tell us about their experiences. We therefore spent time directly observing care practice, noting the behaviour and body language of individuals we were unable to communicate with, to assess their state of wellbeing. We took note of the quality of interactions between these individuals and staff, also with other people using services and with their environment. We observed medication practice and practice at lunch time and during an evening meal. We also observed a group social activity facilitated by an occupational therapist. We wish to thank all who contributed information to the inspection process. Also all people using the homes services, staff and management for their time, hospitality and cooperation throughout this inspection. What the care home does well: What has improved since the last inspection? A suitably qualified and experienced home manager had been appointed in April 2008. She had implemented a number of positive developments and improvements in the areas of care planning and assessments since taking up post. The home manager had drawn up an action plan for raising standards, with achievable targets for sustaining and making further improvements. The home manager was also driving up standards through her commitment and progression of the staff training and development programme, to ensure a skilled and competent workforce. The focus over recent months has been on ensuring all staff Care Homes for Older People Page 8 of 38 receive statutory and refresher training. It was good to note the recent inclusion of dementia care training in the staff training programme. Significant investment had gone into the premises over recent years, to upgrade and refurbish the environment. Safety locks had been fitted to bedroom doors and to items of furniture in bedrooms and carpets and soft furnishings replaced. Since the last inspection the homes fire safety systems have been upgraded and a new kitchen floor laid. Two adjustable height beds had also been purchased. The home manager had rearranged the lounge furniture to the benefit of people using services. This had created a less institutional environment, arranging chairs in a way that encourages social interaction between people using services. Since the inspection visits the providers have told us of recent work carried out to enhance safety in the environment. The shortfalls in medication training and practice identified at the time of the random inspection last year have been rectified. The homes medication policies, procedures and practices now ensure the health and welfare of people using services. Whilst staffing levels were not adequate at the outset of this inspection visits this has also been improved. What they could do better: Over a significant period of time the home has not had a registered manager for a sustained period. Since the last key inspection several managers were appointed and left in rapid succession. The home manager appointed in April 2008 made application for registration but since then has withdrawn the same on the basis of having tendered her registration. Her reasons for this are referred to in the main body of the report. The failure to replace the registered manager with a competent and skilled new person in the management role indicates deficiencies in the organisation’s recruitment and management procedures. A requirement has been made for the home to have a registered manager. It has also been required for the homes assessment tools and processes to be further developed to ensure the health, safety and independence of people using services. Whilst the principles of respect, dignity and privacy are put into practice, at the time of the first visit to the home, staffing levels were a constraint to maintaining adequate observation of people using services. The outcome was a failure to ensure the dignity of a person using services on one occasion. Feedback from some staff confirmed recognition of the need to spend more time with people using services. They had been unable to do so on staffing levels at the time of the inspection visits. The need to monitor night staffs practice specific to the time of serving breakfasts, to ensure the choices and rights of people using services are respected, was discussed with management. Though the care records sampled included diversity information specific to ethnicity, gender, age, religion and disabilities, they did not all address diversity needs. Observations included failure to address the disability needs of one person, or communication needs of people with dementia and of inappropriate practice. This Care Homes for Older People Page 9 of 38 demonstrated the need for monitoring arrangements to be in place to make sure diverse needs are met; also for staff to receive training in equality and diversity. A key worker system is in operation and key workers are delegated responsibility for monthly evaluation of care plans. Shortfalls specific to their practice were identified. It was agreed that key workers will receive further training and support. Also discussed was the need to ensure they have sufficient time for this role and responsibilities. Whilst the meals are varied and offer a choice of home cooked food and meet individual diversity, cultural and dietary needs and preferences, attention is necessary to portions sizes of particular foods. A requirement has been made, to ensure the nutritional needs of people using services are fully met. A further requirement has been made for improvement in arrangements for monitoring weights. Currently the home does not have suitable equipment for this purpose. Key workers also must receive training to ensure they report significant variations in weight to ensure appropriate action can be taken. The strengths in the homes social activities programme, with input from external volunteers, entertainers and professional is acknowledged. However, at the time of the inspection visits staff did not have time to ensure adequate social stimulation and engagement for some individuals. We have been informed since the inspection visits that staffing levels have been reviewed and increased. The layout of the building and lack of signage does not promote independence. A requirement has been made for health and safety risk assessments to be more robust. A system must be in place for effective audits to be carried out to ensure the safety of people using services. An immediate requirement was made for assessment of risk to people using services relating to the unrestricted access to a flat roof and fire escape and balcony. The providers have since responded appropriately to minimise these risks. Other improvements include the requirement for staff recruitment procedures to include obtaining a medical declaration for all prospective staff. Access to staff records needs to be restricted to ensure confidentiality of information about staff. Attention is also necessary to the storage, recording and disposal of staffs Criminal Records Bureau disclosures. Most staff had received a basic induction. The expectation for the the Common Induction Standards to be used for the induction of new staff was discussed with the home manager. These set out the learning outcomes that need to be met so that new workers know all they need to know to work safely and effectively. They also help support staffs continuing professional development, preparing workers for entry onto the appropriate Health and Social Care Vocational Qualification (NVQ). If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 Care Homes for Older People Page 10 of 38 240 7535. Care Homes for Older People Page 11 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 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available to enable prospective people using services and their representatives to choose a home that will meet their needs and aspirations. The assessment process underpinning admission decisions needs to be further developed to fully ensure the safety and wellbeing of people using services. Evidence: A statement of purpose specific to the homes services and facilities and user groups is displayed in the home and a service users guide. These documents provide up to date information about the home and describe to prospective people using services how the home runs, so they know what to expect. They set out the homes philosophy of care also the service aims and objectives and include information about staffs qualifications and the complaints and compliments procedure. A copy of the homes latest inspection report is prominently displayed by the front entrance. Service provision includes respite care, provided the home has a vacancy, but not intermediate care. Noting the Care Homes for Older People Page 13 of 38 Evidence: service users guide is produced in one standard format, it was suggested this be available in a range of formats, including large print. This will enable people with diverse communication needs to access this information, ensuring an informed choice of home. Discussions with a person using the homes services confirmed she had received opportunity to view the home, with a relative, prior to her admission. This had helped her to decide on its suitability to meet her needs and wishes. When she visited she said that staff had been warm and welcoming, responding to her queries and allaying her worries and anxieties. Another person that was admitted directly from hospital said her nephew visited and chose the home on her behalf. She had been happy to trust his judgement and was overall very pleased with the home. Malmsbury House has a clear admissions criteria and its admissions policy promotes equality and diversity. There is an unusual approach to pre-admission assessment arrangements in that assessments are exclusively carried out at the home. Prospective people using services are invited to visit for assessment and offered opportunity to stay for a meal. Clarification was sought on how this process worked for people admitted from hospital. The home manager advised that on the day of their proposed discharge they are transported to the home by ambulance for assessment. A verbal agreement was stated to be made with hospital staff for the hospital discharge process not to be concluded until the outcome of the homes assessment establishes that the individuals needs can be met. Prior to this the home manager would have widely consulted relatives, hospital staff and other professionals, gathering relevant information. Additionally, relatives or a representative of the person would have viewed the home. Assessment summaries from the hospital and from care management, where available, would also have been sought.The home manager emphasised that on the basis of all this information it is usually evident before carrying out the homes assessment whether or not the needs of prospective people using services can be met. The assessment approach was observed to be person-centred, mostly identifying cultural and diversity needs and focused on achieving positive outcomes. Since taking up post earlier this year, the home manager had developed the assessment process, incorporating into it a validated falls risk assessment tool. The inspection process identified the need for risk assessments to be more comprehensive, to ensure environmental hazards and potential barriers to independence are identified. On the basis that the majority of the homes current population have varying degrees of dementia, assessments should also consider special communication needs, for example, use of signage and other visually orientating information, to aid orientation around the home. Areas of discussion with the home manager included the need to Care Homes for Older People Page 14 of 38 Evidence: arrange professional assessments for two people using services to ensure their needs are fully met. Care Homes for Older People Page 15 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. Health and personal care delivery is based on individual needs assessments and set out in a plan of care. Systems for monitoring weights and responding to significant variation in the weights of people using services must be more robust to ensure their health and welfare. Whilst the principles of respect, dignity and privacy are overall put into practice, staffing levels were a constraint to staff being able to preserve the dignity of a person using services at the time of one of the inspection visits. Medication policies and procedures ensure the health of people using services. Evidence: The home manager had implemented a number of changes since taking up post. These had developed and improved needs assessments, care planning and record keeping. There was a clear action plan with achievable targets for sustaining these improvements and for further improvements. The home manager had prioritised the action plan, concentrating her time initially on the management and delivery of care and on staff, to ensure they have the skills and knowledge base they need, through a structured, ongoing training programme. Since the homes last key inspection there Care Homes for Older People Page 16 of 38 Evidence: had been poor continuity in the homes management. A significant turnover in home managers in the past year had led to shortfalls in standards which the current home manager is striving to improve. A key worker system is in operation and key workers are delegated responsibility for monthly evaluation of care plans. Prior to the home manager taking up post, systems for reviewing and updating care plans had been less robust. Some shortfalls in the practice of key workers identified during the inspection visits were discussed with the home manager and the providers representative. It was agreed that key workers will receive further training and their practice will be monitored. Key to improvements in this area is the need to ensure adequate staffing levels to allow key workers sufficient time to fulfil their role and responsibilities. Six care plans and associated records were sampled as part of the inspection process. These care plans had been generated from needs and risk assessments. As identified in Outcome Area 1 of this report, the risk assessment tools need to be more comprehensive. Though positive to see the recent introduction of a falls risk assessment, unfortunately, where the risk of falls had been identified, care plans did not sufficiently detail the actions expected of staff to reduce the risk. It is not meaningful to staff to record that these individuals must be observed at all times. The expectation of staff needs to be clarified and be realistic in terms of staffing levels, the range of duties expected of care staff and the buildings layout and complexity. The care plan for one such individual could not be followed in practice on the staffing levels observed on the late shift. During discussions with staff who work on night duty, it was evident they were unclear of the level of observation expected for this person. Other shortfalls in the same persons care plan were highlighted to the home manager. Specifically the plan was not clear about the management of continence. A night care assistant stated this person wore incontinence pads at night however this individual had not been assessed for the same and this was not specified in the persons care plan. The home manager confirmed the expectation for staff to be enabling this person to use the toilet at night. A professional assessment of the immediate environment of this person, who is partially sighted, was also discussed, to ensure her safety and quality of life. The lighting in this persons bedroom is dim and a higher wattage bulb and a wider light-shade might be more appropriate, to diffuse the light more evenly around the room. Other improvements in this room could be achieved by colour contrasting the en suite door frame. As referred to in Outcome Area 1 of this report, information needs to be reproduced for this individual in large print, including the new menus in the process of being developed and complaint procedure, in addition to the service users guide. This person would also benefit from large print signage at eye level in public areas. Care Homes for Older People Page 17 of 38 Evidence: With the exception of one care file for someone very recently admitted, the others sampled contained qualitative life history information. This affords staff opportunity to gain a good understanding of each persons character and personality, likes and dislikes and personal interests. The care records sampled all included diversity information specific to ethnicity, gender, age, religion and disabilities. Whilst the care plans were overall well written, not all fully address individual diversity needs. An example has already been given of the failure to address the disability needs of one person. Other findings included inappropriate staff practice that did not respect the religious beliefs of another person. Current good practice recommends that care homes have a procedure for dietary and nutritional assessment, with appropriate first line dietary interventions and when and how to refer to a specialist. Though the assessment format used does include diet and weight, this area is not being adequately assessed or monitored. A validated assessment tool should be used for this purpose. In addition to special dietary requirements and preferences, assessments should incorporate assistance with eating and drinking, condition of oral health and swallowing problems. Observations confirmed a person currently in hospital had lost a substantial amount of weight over a two month period, whilst at the home. This had been recorded by care staff who failed to recognise the significance and had not alerted the home manager. The care notes of this individual did not explain his weight loss, neither did the system for recording and monitoring appetite. Other areas of discussion with the home manager and the providers representative included the need for assessments to address the abilities of people using services to make decisions. Also for the care planning process to be more inclusive, ensuring that people using services are consulted about decisions relating to their care and lifestyle. The importance of ensuring environmental risk assessments take place for each person using services was discussed. Also the need for assessment of the impact of the environment on people with dementia and for this to be addressed in care plans. Whilst the home is beautifully maintained and comfortably and tastefully furnished, it is important to look at the environment from the perspective of people currently using services, most of whom have dementia. Environmental factors have an effect on the process of communicating with these individuals. The environment should provide orientating information. The need to review routines for serving breakfast was also identified, to ensure all people using services have a choice of having a late or early breakfast. It is important to consider whether night staff serving breakfasts is in the best interest of people using services. It was agreed with management that their practice in this area would be closely monitored. Arrangements for health and personal care mostly safeguard the privacy and dignity of Care Homes for Older People Page 18 of 38 Evidence: people using services. An occasion when the privacy and dignity of a person using services was compromised was brought to the attention of management. The need to ensure adequate observation of people using services at all times was discussed. This was one of a number of indicators during the inspection visits that staffing levels may be too low. People using services have access to health care services. They are registered with general practitioners and district nurses provide any necessary input to their health needs, to ensure their health is promoted and maintained. The homes medication policy, procedure and practice guidance is efficient and staff all have access to this written information. The storage, recording, administration and disposal of medication protects people using services. A monitored dosage system is supplied to the home by a community pharmacist. Staff with designated responsibility for medication administration had receive relevant training. They told us their practice had been assessed to ensure their competence. Discussion took place about whether a limited supply of homely remedies might be stocked. This was following an observation that a person using services had asked staff to purchase medication for indigestion using her money. It was suggested the home manager consult the general practitioners if it is decided to make this provision. A detailed protocol for homely remedies will need to be developed. Care Homes for Older People Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the homes services are enabled to make choices in their daily lives and supported in maintaining contact with family and friends. Meals are varied, affording choice and respect individual food preferences, accommodating diversity and cultural dietary needs. Some aspects of catering however must be reviewed to ensure the nutritional wellbeing of people using services. The homes social activities programme affords oportunities for people using services to participate in a range of social activities. The need to increase the level of social engagement for some individuals was identified. Evidence: The first inspection visit was carried out on the late shift when two care staff were on duty. The manager had taken the afternoon off in lieu of additional time worked when the provider had been on leave. The majority of the people using the homes services were sat in the lounge unoccupied, with no music and television on for a large proportion of the shift, whilst both staff members engaged in various duties. Though it is recognised that people with dementia benefit from a quiet atmosphere, staff need to have time to take a more individualised approach to meeting social care needs. Care Homes for Older People Page 20 of 38 Evidence: Though staff maintained an oversight of people in the lounge, their contact with them and other people in their bedrooms, including a person who was physically frail, was totally task led. Staff both engaged in a range of duties in addition to personal care provision throughout the shift. These included serving tea and cakes in the lounge in the afternoon and heating up and serving the evening meal, preparing the dining room, cleaning and tidying the kitchen and dining room after the meal. The senior care assistant was additionally responsible for medication administration and office administrative tasks, answering the door to visitors and dealing with telephone calls. She had also been expected to review care plans that afternoon, though this was postponed to give time to the inspection process. Apart from serving tea and cakes to people in their rooms in the afternoon, staff had no time to carry out regular observations of these individuals and were unable to follow care plans for minimising risk of falls. It is acknowledged that the home has an activities programme and a seniorcise exercise to music group activity took place in the afternoon, provided by an external occupation therapist. This activity was stimulating and evidently much enjoyed by the people in the lounge. It was positive also to observe a volunteer in the home, following this activity, who had come in to talk with people using services. An activities programme displayed in the entrance hall showed a range of activities provided across the week. The same occupational therapist comes in twice weekly to facilitate a game of bingo on Saturdays as well as the seniorcise class on Fridays. Holy Communion is provided by a visiting minister on Mondays, on Tuesdays a hairdresser visits, and on Wednesdays there is an afternoon sing-a-long with staff or with someone who comes in to play the piano. On Thursdays an art class takes place and on Sundays staff manicure nails. The home has a supply of books from a mobile library. The home manager acknowledged the need to have a board in communal areas providing orientating information. It would be helpful to provide reminders of the day, date, weather, staff on duty and meals. The home manager stated this was planned as an aid to communication and short-term memory, also the purchase of additional activity materials suitable for use in a dementia care environment. Though staff had not yet received the dementia care training which was took place after the visits, they were mostly observed to communicate appropriately with people using services. Good practice observations included staff being calm and patient in their approach and speaking slowly and simply, allowing people time to process what they said and waiting for their response. The home employs two cooks who work on opposite days, covering the week. They prepare lunch and the evening meal. The evening meal is heated up and served by care staff who are also responsible for ensuring dishes are washed and the kitchen and dining room left clean and tidy. The cooks are responsible for kitchen hygiene and for Care Homes for Older People Page 21 of 38 Evidence: the safety of food storage but not involved in the preparation of menus and have no control over food orders. The home manager confirmed compliance with requirements made by the Environmental Health Officer in 2007, at the time of the last inspection of the kitchen and of food safety. Most care staff had received food hygiene training and the cook on duty at the time of the visit stated he had a catering qualification and a current food hygiene certificate. The kitchen was clean and the cook stated that all kitchen appliances were functional. The cook was very busy on day two of the inspection visits. In addition to preparing and serving lunch and preparing the evening meal, he was dealing with food deliveries, baking a meat pie and desert for lunch and cakes for afternoon tea. It was good to observe the menus provide wholesome, home cooked food. Discussion took place with the home manager and the providers representative however on the need to ensure adequate nutritional content of lunch for people using services when roast chicken is on the menu. It was established that one small chicken was used to prepare a meal for fifteen people. The providers must ensure this is reviewed and take professional advise in this matter. The quantity of chickens used per meal and of meat should not be left to the discretion of catering staff but based on nutrient standards for older people. It was good to note the manager had instituted regular meetings with people using services. These afforded them an opportunity to influence some decisions and to comment on the menu. The manager stated that some suggestions made by people using services had been incorporated into a revised menu. The home provides three full meals served daily. Pre-admission assessments take account of special dietary needs and preferences and any diversity or cultural dietary needs. This includes the option of a cooked breakfast. Noting that this was decided at the time of admission it would be good practice to review peoples choices in this matter from time to time. A good standard of catering was observed over the two day inspection and portion sizes appeared substantial. The dining tables were nicely laid and the atmosphere at meal times was congenial. Staff wore protective aprons when preparing and serving food. Discussions with the home manager included the observed practice of a carer standing whilst providing assistance to a person using services with her meal.The home would benefit from the purchase of fold-away chairs for staffs use in the dining room to be able to sit down when assisting people with meals, as space in this area is limited. The home manager was also requested to ensure the menu is accessible to people using services. It was positive to hear that work is in progress for producing daily menus to display on dining tables. It is important to ensure that the format of these menus is suitable to meet individual needs. As stated previously in the report, nutritional assessments were not in place. Additionally, staff were unable to accurately monitor the weight of all people using services without provision of suitable weighing scales. It is important for this to be addressed and the homes management has Care Homes for Older People Page 22 of 38 Evidence: confirmed the intention to do so. A number of people were observed to have health related conditions necessitating their appetite and food consumption be closely monitored. The current system for doing so was clearly flawed based on observations during this inspection. Staff had been too busy at the time of the inspection visit to notice that a person using services had not eaten her meal. Visitors are encouraged and those present at the time of the inspection visits were welcomed by staff and gave positive feedback about the home. It was good to observe arrangements for regular meetings between management and relatives. Care Homes for Older People Page 23 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 who use the service are able to express their concerns. They are protected from abuse and have access to an effective complaint procedure. Evidence: We have not received a formal complaint about the home since the last key inspection. An anonymous source contacted us recently with concerns about alleged institutional practices and routines at the home and about the adequacy of meals. This information was used to focus the practice observations during the inspection visit. The allegations and outcome of these observations were fully discussed with management. The home has a compliments and complaint procedure. This is specified in the statement of purpose and service users guide. A copy of this procedure was displayed on the back of bedroom doors and content noted to be in need of revision. The providers contact details must be included also accurate contact details for the Commission for Social Care Inspection. The need to reword the procedure was also discussed, to be clear that the investigation of complaints is the responsibility of the providers. The home had dealt with two complaints since the last inspection. These had been upheld and were now resolved. Eight compliments were recorded as received by the home between May and September 2008. A number of visitors had given the manager positive feedback when she rearranged the lounge furniture. One card from a relative was noted to say, Thank you all for the expert care you have given to our Care Homes for Older People Page 24 of 38 Evidence: mother. She was always so well presented whenever we saw her and very secure in a homely environment. Another stated, Thank you all so much for looking after mum so well, I hope to come to see you again, mum enjoyed her stay. There is a safeguarding adults procedure and policy in place and staff have access to and are aware of the homes whistle blowing procedure. The need to obtain an up to date copy of Surreys multi-agency safeguarding procedures was identified. Two safeguarding adults incidents were investigated by Surreys safeguarding team since the last inspection. We carried out an unannounced random inspection as a result of one of these incidents. This related to an allegation about medication practice which was unsubstantiated. The inspection did however identify shortfalls in medication record keeping practices and the need for staff to receive further medication training. These shortfalls have since been addressed. The other incident had been resolved and correct procedures were followed. Staff had received safeguarding adults training and the manager had undertaken this training in the past. The manager was advised to apply for a place on Surreys safeguarding adults training. Care Homes for Older People Page 25 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. The physical environment of the home is clean and hygienic and the standard of decor and furnishing is good. The layout of the building and lack of signage however does not promote independence. There is a need for the home to have more robust systems for identifying environmental hazards. Evidence: The reception was welcoming with attractive floral arrangements in this area and other communal areas. The home environment is well maintained, comfortably furnished and tastefully decorated to a high standard. Bedrooms are personalised with possessions and items of furniture brought in by people using services, from their own homes. Bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of people using services. Noting one bath was out of commission during the inspection visit, it was confirmed by the manager that consideration was being given to converting this bathroom into a walk in shower room, to further enhance existing facilities. All areas were clean and hygienic and odour control was overall well managed. People using services said there is always plenty of hot water and the temperature in the home is comfortable. Care Homes for Older People Page 26 of 38 Evidence: The shared areas provide a choice of communal space with opportunities for people using services to meet relatives and friends in private. Significant investment has gone into upgrading and refurbishing the environment in recent years. This includes safety locks fitted to bedroom doors and to items of furniture in bedrooms and replacement of carpets and soft furnishings. Since the last inspection the homes fire safety systems had been upgraded and a new kitchen floor laid. A maintenance person and gardener is employed. The grounds at the rear of the home are maintained to a high standard and the car park to the front was tidy. There is also a furnished courtyard with sun-shade for people using services to sit, in fine weather. Since the last inspection two adjustable hight beds had been purchased to enable an immediate response to meeting the needs of people who are acutely ill or receiving terminal care. It was noted that the home manager had ensured access to a suitable pressure relieving mattress and other equipment through the district nursing service for a person in receipt of terminal care, prior to the purchase of these beds. It was noted that the home also has two overlay mattresses. Comment has been made earlier in the report about the complex layout of the building and the need for signage to create a more positive environment for people with dementia. Also the need for attention to lighting in the bedroom of a person who is partially sighted. The need for a professional assessment of this persons environment was advised to ensure her needs are met. The providers must ensure the home has adequate equipment or other suitable arrangements for staff to monitor weights. An assessment of the seating for a person using services was identified for another person using services, to ensure her safety and comfort in the dining room. Comments on environmental hazards are recorded in Outcome Area 7 of this report. Care Homes for Older People Page 27 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. The shortfall identified in staff recruitment practice must be rectified. Whilst staffing levels were inadequate at the time of the inspection visits, this has since been rectified. The homes management is committed to staff training and development through a structured programme of training. The staff induction programme however needs to be improved. Evidence: The home has a small, multi-cultural staff team. Staff turnover since the last inspection has included several newly appointed home managers and three part time care assistants. Discussion took place with the manager about the importance of improving staff retention in the best interest of people using services. There is a deliberate strategy of employing part-time staff to ensure flexibility. Care staff work twelve hour shifts and rotas are planned well in advance. Whilst people using services stated the care received met their expectations, the practice on the late shift was observed to be task led and failed to provide adequate supervision of all people using services. We followed up a missing persons incident earlier this year, at which time it was evident that staffing levels were not adequate. The providers were requested to review staffing levels which they did and increased the number of care staff on the late shift to three, the same as on the early shift. At Care Homes for Older People Page 28 of 38 Evidence: the time of this inspection however staffing levels had reverted back to two care staff on the late shift. This was in response to a perceived reduction in dependency levels. It is acknowledged the physical dependency of the group had reduced following the death of one person and transfers to hospital and a nursing home of two other people. However the revised levels did not appear to have sufficiently considered the high levels of dependency associated with dementia. When setting staffing levels the homes management needs to also take into account the complex layout of the building and the range of duties that care staff perform, in addition to personal care. The inspection evidenced times when staff were unable to adequately supervise people in all areas of the home or provide appropriate stimulation. The providers representative has confirmed, since carrying out the inspection visits, that additional staff were being recruited. Also that staffing levels had been increased on the late shift, using agency staff where necessary. Staff were very kind and caring in their interaction with people using services. They were professional in their conduct and appearance and generally demonstrated an understanding of their needs. It was evident that individual staff members had developed positive relationships with individual people using services and some visitors. The manager had not recruited any new staff since her appointment. The personnel files sampled identified a shortfalls in recruitment practice, specifically an omission to obtain medical declarations from employees.The manager stated she would take remedial action in this matter. Discussion also took place regarding the need for confidential storage of personnel files. There is a need to restrict access to confidential personnel information including references, Criminal Records Bureau (CRB) disclosures and supervision and disciplinary records. The need to adhere to the CRB guidance for recording, storage and disposal of disclosures was discussed. All staff had received two one to one supervision sessions with the home manager since her appointment. During these she had spent time identifying training and development needs. A rolling programme of staff training had been reinstated and it was positive to see this included dementia care. The home manager confirmed she had a training for trainers certificate in dementia care and planned to imminently deliver this training to the team, using the Alzheimers Societys training materials. Five care staff were stated to have qualifications in care to NVQ Level 2 or above. A programme of NVQ training was ongoing for four staff. Observations confirmed the need for staff to have diversity training specific to the religious beliefs of people using services, to ensure appropriate practice. Feedback from staff on duty and from two who completed surveys confirmed they had Care Homes for Older People Page 29 of 38 Evidence: received an induction when they first took up post. Some felt this had been generally adequate, others acknowledged this had been basic. One care assistant reported not receiving any form of induction.The home manager was reminded of the need to ensure new staff receive an induction and for this to cover the the Common Induction Standards developed by Skills to Care. These set down minimum expectations as to the learning outcomes that need to be met. This will ensure that new workers know all they need to know to work safely and effectively. Care Homes for Older People Page 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes continuing management instability is having an adverse impact on standards and the conduct of the home. Improvement is necessary to staff recruitment practices and a more robust approach to risk assessment and risk management is required. Quality monitoring systems are inclusive and the financial interests of people using services are safeguarded. Evidence: Two of the registered providers are not based in this country and the operation and conduct of the home is largely overseen by the partner living local to the home. Due to circumstances outside of her control this partner has not always been available to oversee its management in recent years. This has been carried out by a relative who had also periodically managed the home. Currently the provider is directly involved in the day to day management of the home and visits most days to oversee its management and operation. Care Homes for Older People Page 31 of 38 Evidence: The home has not had a registered manager for a number of years. There has been a number of unsuccessful appointments to the post of home manager since the last key inspection, prior to the appointment of the current manager in April 2008. Since the inspection visits the home manager has submitted an application for registration however this has since been retracted. The home manager stated she had reluctantly given in her her resignation out of concern, based on her experience, about the lack of support she is receiving to enable her to fulfil her management role and responsibilities. She felt that without this support and more autonomy in decision making that she would not be able to raise standards and ensure best practice. This is very disappointing, given the homes history of management instability. The AQAA confirmed that the home manager had the relevant qualifications and experience, including a dementia trainer certificate, to implement and sustain the necessary improvements. At the time of the key inspection she had communicated a clear sense of direction and leadership to the staff team. Staff feedback and the general atmosphere of the home indicated good teamwork developed under the home managers tenure. Observations indicated that staff, also people using services and their advocates, liked and respected her. Areas of discussion with management during the course of this inspection included the need for a more proactive approach to the management of risk. The use of additional risk assessment tools was advised to ensure the safety and welfare of people using services. Recent examples of shortfalls in this area included a missing person incident when a person admitted for respite care left the building without staff being aware. Whilst it is acknowledged that after we contacted the providers representative in this matter appropriate action was taken to prevent a similar occurrence in the future, it was a concern that this risk had not been addressed without our intervention. Observations during this inspection highlighted the need for a more proactive approach to risk assessments in general. Immediate requirements were made at the time of the inspection visits for urgent assessment of the risk to people using services regarding their unrestricted access to a flat roof on the first floor, leading to a fire escape, and balcony. Appropriate action was taken to minimise this risk within the required timescale. The providers have since informed us that this risk had already been identified and contractors had been commissioned to carry out the necessary work, however this had been delayed for reasons outside of their control. We were told that the provider had instructed staff to be extra vigilant to ensure the safety of people using services. Observations however confirmed no record of assessment of this risk or risk management controls in place. Also it was evident that owing to staffing levels having been recently reduced, that staff were not always able to ensure adequate supervision of all people using services. Feedback was also given to the manager at the time of the visits that some night staff were using the bed rails integral to the two new beds. The people occupying these beds were stated not to need the use of bed Care Homes for Older People Page 32 of 38 Evidence: rails. Their use without appropriate risk assessment posed a potential risk to their safety. It was good to observe the substantial investment in the homes security and fire safety systems since the last key inspection. Also to note that since the inspection visit staffing levels had been reviewed and increased. The homes quality assurance systems incorporate use of surveys for canvassing the views of people using services, their relatives and visitors. The home manager had instituted meetings with people using services also with their relatives and representatives. These afforded opportunities for them to influence decisions, ensuring the home runs in the best interests of people using services. A new development since the last key inspection had been a system for the safekeeping of money on behalf of people using services. The financial records sampled confirmed the practice of recording all transactions and maintaining receipts for any expenditure on their behalf. The manager was advised to implement an auditing system for these accounts. It was also suggested that she check the balance of money held against the financial records during shift hand-overs. There has been no change to the previous arrangement for additional costs not included in fees to be invoiced each month to the representatives of people using services. Care Homes for Older People Page 33 of 38 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 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 4 14 The homes assessment 31/10/2008 tools must be further developed to ensure a positive and safe environment for people using services. Assessments must be kept under review and revised in response to any change of circumstances and needs. This will ensure the homes capacity to meet the assessed needs, including specialist needs of individuals admitted to the home. 2 7 15 Care plans must be further 24/11/2008 developed and generated from a comprehensive needs and risk assessment. This will ensure the health, safety and welfare of people using services. 3 8 12 For arrangements to be in place to ensure weight loss or gain is monitored for all 24/11/2008 Care Homes for Older People Page 35 of 38 people using services and appropriate action taken in response to significant variation in the same. This will ensure the home promotes and maintains the health of people using services. 4 15 16 For the home to provide at 03/11/2008 all times adequate quantities of food to ensure the nutrition of people using services. This will ensure the health of people using services. 5 29 19 For staff recruitment procedures to include evidence of prospective staffs physical and mental fitness for the purpose of the work they are to perform. Where this is impracticable, prospective employees must sign a declaration that they are fit. This will ensure the protection of people using services. 6 31 8 The registered person must appoint a suitably qualified, competent manager to manage the home and ensure the manager is able to discharge his or her responsibilities fully. The home manager must be supported in making application for registration. This will ensure the home is 31/10/2008 24/11/2008 Care Homes for Older People Page 36 of 38 managed by a person who is fit to be in charge; also that it is managed to meet its stated purpose, aims and objectives and is run in the best interest of people using services. 7 38 13 For the approach to risk assessment and risk management to be more robust. This will enhance the health, safety and welfare of people using services. 14/11/2008 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 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) 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. 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