Inspection on 19/06/09 for Maristow House Nursing Home

This inspection was carried out on 19th June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maristow House Nursing Home 25/11/09

Maristow House Nursing Home 31/07/07

Maristow House Nursing Home 11/08/06

Maristow House Nursing Home 07/02/06

Maristow House Nursing Home 10/05/05

Maristow House Nursing Home 18/01/05

Maristow House Nursing Home 23/08/04

Maristow House Nursing Home 01/03/04

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Fairfields Country Rest Home

Queensmount

Poldhu

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 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Maristow House Nursing Home 16 Bourne Avenue Salisbury Wiltshire SP1 1LS     The quality rating for this care home is:   zero star poor 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: Susie Stratton     Date: 0 9 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 45 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 45 Information about the care home Name of care home: Address: Maristow House Nursing Home 16 Bourne Avenue Salisbury Wiltshire SP1 1LS 01722-322970 01722337485 maristow16@hotmail.co.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) : Mrs Lindsey Jayne Wallace care home 17 Number of places (if applicable): Under 65 Over 65 17 0 2 old age, not falling within any other category physical disability terminally ill Additional conditions: 0 17 2 No more than 2 service users with a terminal illness may be accommodated in the home at any one time The maximum number of service users who may be accommodated in the home at any one time is 17 The minimum staffing levels set out in the Notice of Decision dated 16 January 2004 must be met at all times Date of last inspection Brief description of the care home Maristow House Nursing Home is a large town house, located in a residential area, which has been converted for use as a care home. The home is situated in the city of Salisbury, Wiltshireand is within easy reach of the city centre. The accommodation is provided over two floors of the home, with the majority of the bedrooms provided being single. Maristow House is registered to provide nursing care for 17 people. The home is privately owned by Mrs Lindsey Wallace who is also the registered manager. Care Homes for Older People Page 4 of 45 Brief description of the care home She leads a team of nursing and care staff; a cook and adminstrator are also employed and Mr Wallace, Mrs Wallaces husband, is actively involved in the running of the business. The fee range is 600 pounds to 850 pounds a week. Care Homes for Older People Page 5 of 45 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection peterchart Environment Staffing Management and administration Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 14 questionnaires were sent out and seven were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. The homes file was also reviewed and information obtained since the previous inspection considered. We received an Annual Quality Assurance Assessment (AQAA) from the home between the two days of the inspection. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what areas we should focus on when drawing up this inspection report. Care Homes for Older People Page 6 of 45 Two site visits were performed at Maristow House by one inspector. This person is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The first site visit was on Friday 19th June 2009, between 8:50am and 4:50pm. The second site visit was on Thursday 9th July 2009 between 1:50pm and 4:20pm. The first visit was unannounced. There were several days between the two inspection visits as we were awaiting the completed AQAA report. Mrs Wallace was in the home on the first day of the inspection working a management day. A registered nurse was in charge of the home. Mr Wallace was available for all of the feedback and Mrs Wallace was available for parts of the feedback, at the end of the site visits. During the site visits, we met with five residents and observed care for six residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for five residents, including a resident who had recently been admitted to the home and looked at specific records relating to a further three residents. As well as meeting with residents, we met with two registered nurses, four carers, the domestic, the administrator/training manager and the chef. We observed a lunchtime meal. We reviewed systems for storage of medicines and observed one medicines administration round. A range of records were reviewed, including staff training records, staff employment records, complaints records and maintenance records. What the care home does well: What has improved since the last inspection? What they could do better: The home needs to develop across a range of areas to improve service provision. Pre-admission assessments need to consider a residents placement in the home and lifting aids required by them. Once a person is in the home, assessments need to be completed in a prompt manner. If complex issues are identified relating to meet needs, full and detailed assessments need to be developed. Consistency in approach needs to be developed towards care plans. If a person has a need or a risk is identified, care plans must always be put in place to show how the persons need is to be met or risk reduced. Care plans need to use precise, measurable terminology. If a persons needs have changed or new interventions are indicated, care Care Homes for Older People Page 8 of 45 plans need to be updated. If a person is not able to meet their own activities of daily living, monitoring charts need to be accurate and comply with care plans and researchbased evidence. Systems for management of medicines need to be approved. Risk assessments must be drawn up for medicines to be given in an emergency if they are not locked away. Medicines must only be given where the person has a prescription. Where medicines are prescribed on an as required basis, there must be a care plan or protocol for their use. Residents prescribed medicines must not be used for other residents. Clinical items must not be used after their expiry date. Medicines for residents who are not longer in the home must be disposed of promptly. There must be clear documentary systems relating to Controlled Drugs. Where a person is assessed as being at risk of social isolation, care plans must always be in place to direct staff on how risk if to be reduced. Resident profiles should be further developed. All staff who support residents in activities should document how they have supported the resident, including benefit of activities to the resident. Staff must be regularly trained in safeguarding vulnerable adults from abuse. All staff must be made aware of their individual responsibilities for protecting residents. Where issues have been identified as part of safeguarding investigations, there must be evidence that the home has taken full action to address similar issues which may affect people living in the home. The home must develop its practice in relating to infection control and ensure that personal and clinical items are not used communally. All sanitary equipment must be promptly cleaned after use and left dry. Sanitary equipment which is no longer wipable needs to be replaced. Used laundry must never be placed directly on the floor. The home must ensure that its recruitment procedure complies with guidelines and ensure that all members of staff working in the home have a proof of identity on their file. Training records need to be up-dated and reviewed, so that the home can evidence that all staff have been trained in mandatory areas, including manual handling and infection control. Systems need to be in place to ensure the health and safety of people in the home, in accordance with current requirements from external agencies such as the health and safety executive and environmental health office. This is particularly in relation to the use of bed safety rails, the use of wheelchair foot-plates, free-standing radiators and access to the kitchen. Managers must ensure that staff comply with directives and individual care plans relating to matters which can present risk to people. We are concerned that this home, which was previously assessed as providing good outcomes for residents, is now assessed as providing poor outcomes to residents. We will be taking action within our procedures to ensure that the home develops improved outcomes for residents. If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 9 of 45 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 10 of 45 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 45 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. Peoples needs will be assessed prior to admission, however there is a lack of emphasis on assessing all needs and completing assessments immediately after admission. Evidence: In their AQAA, the home reported on their open door policy, encouraging people to drop in and to make multiple visits if they wished, with visitors being able to speak with residents and view available rooms. The home reported that changes in decor and furnishings are discussed and accommodated whenever possible, at the time of admission. During the inspection, we met with a range of people, some of whom were able to describe their admission process to the home, however other people were too frail to be able to do this. One person reported that they had decided on this home with the assistance of their family, as it was the home which was closest to all members of their Care Homes for Older People Page 12 of 45 Evidence: family and so made visiting easier for them. Another person reported that they had been in a different home previously but that this home was easier for their relative to visit, as it was closer to a bus route. Staff reported that the manager goes out to visit residents prior to admission to assess their needs and the manager will then inform them of the new persons needs. The cook reported that they tried to go out to meet with all newly admitted residents soon after their admission, to find out their likes and preferences for meals. One person commented that the person who manages the homes administration had been very helpful when they were being admitted. During the inspection we met with a person who had been admitted recently. The person was very frail and unable to recall their admission process. Their records indicated that their condition had improved since their admission in that they were no longer bed-bound, as they had been before admission and now got up every day. We reviewed this persons pre-admission assessment. The person had an assessment both from their previous provider and from the home. The homes assessment document used a scoring system so that the persons dependency needs prior to admission can be assessed. The persons assessment indicated that they remained in bed all the time, as did the previous providers assessment. The assessments indicated that the person needed a hoist for all transfers. The person was to be admitted to a room up a short flight of steps, so the homes pre-assessment should have considered this factor, including the availability of hoists in the home and to ensure that there were no risks associated with moving a hoist up the steps. As stated above, after admission, discussions with staff and records showed that the persons condition improved to the extent that they were able to get up every day and go down to the sitting room. As they were in a room up a short flight of steps and not able to mobilise independently, this was reported to involve the person being bumped in a wheelchair, by male members of staff, up and down the steps. This is not ideal and could present a risk to both the person and staff. A risk assessment relating to this practice had not been drawn up and there was limited reference in the persons records to this practice and how people were to be protected. Nursing and Midwifery (NMC) guidelines state that records should identify any risks or problems that have arisen and show the action taken to deal with them. We discussed the situation with the home managers at the end of the first site visit and advised that although they had admitted this person in good faith, that urgent action needed to be taken before injury occurred to the resident or staff. By the second inspection day, plans had been made to address the situation, however action on this matter should have taken place before the first day of the inspection. Care Homes for Older People Page 13 of 45 Evidence: The persons records showed that a post-admission assessment of their needs had not been completed four weeks after their admission. The person had complex nursing and care needs and assessments of their needs should have been made more promptly. When we visited this person, we observed two opened prescribed mouth washes in the persons room. Neither pre-admission assessment reported on details of a prescription for a mouthwash. We observed that there had been several references in the persons daily records to the need for mouth care, but an assessment or care plan had not been drawn up about this need four weeks after the persons admission. Additionally the person had thickening agent and a dietary supplement in their room. There were no assessments or care plans about these matters. This is of concern. Care Homes for Older People Page 14 of 45 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not have full systems in place to ensure that all of their residents personal and healthcare needs can be met. Evidence: Maristow is a small care home with nursing. This means that staff are in a position to get to know residents individually. Historically the home has tended to cater for people with high dependency needs, this includes younger adults. This was reflected at the time of the inspection, where there were a range of residents with different ages, some of whom had highly complex needs. One member of staff acknowledged this, reporting on the workload as being very heavy, demanding. People commented on the care provided in questionnaires. One person reported that the staff were very good and helpful and another they always put clients need first. A member of staff commented we treat people as individuals also we treat this place as a home, not a nursing home. People commented on how the home met their needs. One person described their poor sight and bad legs, reporting that due to Care Homes for Older People Page 15 of 45 Evidence: this, two staff attended to assist them to transfer from chair to commode or bed to chair using a frame. People reported they could have a shower or a bath and that staff helped them with this. One person reported I have a bath every Tuesday and another I have a shower once a week. However we met with one person who needed thickening agent to assist them in swallowing safely, who reported that at times staff made their drinks too thick in consistency. Many of the residents had compromised communication or found communication complex, so we relied on observation, discussions with staff and reviews of documentation, to assess how such peoples needs were met. Staff reported that they found out about residents needs at handover, which happened every day. One carer described how report gave them information on everything they needed to do. Hand-overs were also reported to be given to night staff and to morning staff after the night shift. Residents had monitoring records in their rooms for staff to document care given and other significant matters. Assessments and care plans were kept in the office, to which all staff had access and we observed during the visits that staff regularly accessed the office to document in care records. In their AQAA, the home described their individualised and person-centred care plans that are responsive, flexible and assess risks for monitoring and reviewing. The home uses a standard system to assess residents nursing and care needs and develop care plans. Assessments and care plans are crucial documents in care homes with nursing, particularly where people have difficulty in communication or are highly dependant on staff to meet all their activities of daily living. Assessments ensure that peoples needs are assessed, including risk to the person. Care plans direct on how to meet peoples needs and ensure consistency in approach by staff. Monitoring records are needed to show that frail peoples needs have been met and provide an over-view of response(s) to interventions. NMC guidelines state that they way a registered nurse records information and communicates is crucial and that assessments and reviews need to provide clear evidence of the arrangements made for future and ongoing care. they also state that a registered nurse has a duty to communicate fully and effectively with their colleagues, ensuring that they have all the information they need about the people in their care. We found that the home showed a variable approach to documentation. People had general assessments of need, which were regularly evaluated. Some care plans were clear, for example people had very clear care plans relating to how their mobility and manual handling needs were to be met. One person had a very clear and detailed care plan relating to how their personal care needs were to be met and another one about how their nutritional needs were to be met. Care Homes for Older People Page 16 of 45 Evidence: However there was a lack of consistency in approach to care planning. One person had a very clear care plan about their artificial feeding system, which documented all required interventions. But another person had a limited care plan, which did not consider the range of interventions needed by the person. One person had a clear care plan relating to prevention of risk of pressure ulceration, which stated how often their position needed to be changed to prevent risk, however three other people whilst they did have care care plans to direct staff on how risk of pressure ulceration was to be reduced, they did not state all interventions such as the type(s) of aid to be used and how often the person needed their position to be changed. As noted above, some care plans were very clear and fully detailed all interventions, however others needed attention. Some personal care plans relating to application of topical creams documented apply creams although the person had several different topical applications in their room. A person who was a diabetic had a care plan stating that their blood sugar levels were to be kept within parameters without stating what the parameters for the person were. The plan stated that their blood sugar levels were to be checked daily/weekly without stating which. People who have diabetes may be at risk from a range of medical complications, therefore care plans need to be clear, to ensure that staff can properly support the resident. Care plans for people with urinary catheters did not state the clinical reason for use of the catheter and one care plan indicated that the catheter was a continence aid. As urinary catheters present a risk of infection, they should only be used if they are in the best interests of the person, so the reason for their use should always be documented. Urinary catheters are not continence aids. Some people had their care plans evaluated regularly to ensure their continued relevance to the person and had plans up-dated when their condition changed, others did not. For example one person had not had a care plan about a complex need evaluated for four months, despite evidence of different interventions elsewhere in their records. There was evidence to indicate that some care plans needed up-dating and evaluation. One person who was fed artificially had an assessment which was dated after the care plan. The evaluation did not reflect the care plan or what we were informed by a carer about what the person was able to eat. Another persons assessment stated their preferences for personal care, which was not what not what was documented as taking place in practice. Another person had a dietary supplement in their room, which they were being given but this was not documented in their care plan. If assessments and care plans are not fully up-to-date, there is a risk that the person will not have their needs met. While as noted above, some residents had very clear care plans directing staff on how their needs were to be met, other people did not have care plans about significant Care Homes for Older People Page 17 of 45 Evidence: needs. This included two people who clearly had issues relating to continence but did not have care plans to direct how their needs were to be met and resident had a stoma but did not have a care plan about this. If people do not have care plans about how their complex needs are to be met, there is a risk that their needs will not be met or that they will not be met in a consistent manner. It is also of concern, as a lack of specific care plans to meet a persons needs were identified during a recent safeguarding investigation. Residents had monitoring charts to document that their basic care needs were being met. There is a large body of research-based evidence relating to pressure ulceration. Pressure ulcers, once developed may take some time to heal, are painful and present a risk of infection, so the emphasis must always be on their prevention. The National Institute for Health and Clinical Excellence guidelines (NICE), the European Pressure Ulcer Advisory Panel and local guidelines all state that where a person is assessed as being at risk of pressure ulcers, as well as providing pressure relieving aids, in order to prevent risk of pressure ulcers, people at risk also need to have their positions changed at least four hourly and for those people at higher risk, including people who have sustained pressure ulceration, they need their positions changing two hourly. We looked at records of changes of position for when people were assessed as being at high risk of pressure ulceration. Three of the residents were provided with high tech mattresses which automatically altered the persons position, to prevent pressure ulceration. Other people were provided with aids which research-based evidence shows are effective in prevention of pressure ulceration, but means that the persons positions need to be changed to prevent pressure ulceration. We reviewed monitoring records for five residents who were cared for on an ordinary air mattress, none of which showed that they were having their positions changed regularly, including one person whose care plan stated that they needed to have their position changed three to four hourly. This is of concern, as two residents daily records noted sore areas. Accurate documentation about changes of peoples positions was raised during a safeguarding investigation. The NICE guidelines also state that if a person has pressure ulceration, that time sitting out of bed needs to be limited to two hours. We did observe that where one person was identified as having a sore area that they were put to bed, however records did not show that the person had their position changed two hourly. Frail people had their food and fluid intake documented. Most food charts were completed, however several stated puree, rather than documenting what the person did eat for their meal, this included one person who was not eating the main lunch meal. Fluid charts showed a variability. One reflected in full what we observed. Care Homes for Older People Page 18 of 45 Evidence: Another persons fluid chart documented tea being given to them but a few hours later the tea remained on their table; it was cold. Another person had a beaker of tea in their room and a fluid balance chart which stated that they had been given 100mls to drink but much less that 100mls had been drunk from the beaker when we visited. Three out of the five fluid charts reviewed for the day before the inspection had not been totalled. All of the people who commented in questionnaires reported that they always received the medical support that they needed. One persons records showed that they had been reviewed regularly by the dietitian. The home maintains close links with the tissue viability nurse. We observed in one residents records that where they had been noted as developing an additional medical need, prompt referral had been made to an external health care professional. We observed that where a person who was not able to swallow safely had been prescribed tablets by an external healthcare professional, that prompt referral had taken place to their GP, to ensure that they were prescribed liquid preparations. During the inspection we observed systems for the administration of medication. We observed a medicines administration round and noted that the registered nurse carefully reviewed the medicines administration record, dispensed the medication and observed that the person had swallowed their medicine, prior to signing the persons medicines chart. Where medicines instructions had been changed by hand, these had been checked and counter checked. Where a person was prescribed a medicine that could affect the persons pulse-rate, records showed that the persons pulse was checked before the medicine was administered. The registered nurse showed a good understanding of why two residents had had certain medications reviewed and changed recently. Some areas of practice need improvement. The home does a medicines round at 6am, at the end of the night shift. As much as possible, homes are advised to only administer drugs which need to be given then. This is because the Registered Nurse administering drugs at the end of the night shift may be tired, so medication errors are more likely and residents may also find it difficult to swallow medications when they are woken early in the morning. Homes are advised to contact GPs to discuss this matter with them. In every room we inspected, we observed some prescribed topical applications which were prescribed for a person other than the person in the room. Prescribed medications belong to the person they are prescribed for and must not be used for another person. All prescribed medication must be labelled and only administered to, or used for, the named person. This will ensure that all people receive the correct Care Homes for Older People Page 19 of 45 Evidence: treatment. At least four of these applications were over their expiry date. In their AQAA, the home reported on the tiding up of their medical supplies store. However we noted some syringes and swabs in the clinical room were over their expiry date. This room also included topical applications and one bag of intravenous fluid for people who were no longer in the home, had not been disposed of. Where a person is no longer in the home, their prescribed items must be disposed of promptly. Only medication that is in current use must be kept in the home. Medicines no longer required or past their expiry date must be sent for destruction. This will ensure that people are not at risk of using incorrect medication. When we reviewed the Controlled Drugs, we observed that the quantity of one Controlled Drug did not conform to what was documented in the Controlled Drugs Register. We were informed of why this was, in that a GP had confirmed in writing that a Controlled Drug was to be used for a different person. This is not acceptable practice and has been referred to the Primary Care Trust. The home did not make a record of this matter in the Controlled Drugs Register. We also observed that Controlled Drugs remained in the Controlled Drugs cupboard for a person who had died some three months previously. Much care must always be taken about management of Controlled Drugs and drugs must be promptly disposed of, in accordance with guidelines, after a persons death. When we looked at a persons individual records we noted that suppositories had been given on a certain day but that this had not been documented in their medicines administration record. For a second person we also noted that suppositories had been documented as being given but this person was not prescribed such interventions. Neither person had a care plan about management of their bowel care needs. This is of much concern as management of peoples bowel care needs must be correctly performed, following assessment and development of care plans and drugs must only be given in accordance with prescriptions. A matter similar to this was raised during a previous safeguarding investigation. NMC guidelines state that registered nurses are not to administer any drug which has not been prescribed. In one room, we observed that a resident had a notice relating to a drug to be given in an emergency. This drug was kept in an un-locked cupboard. The persons medicines administration record did not have a current prescription for this medication. Mrs Wallace reported that the resident did not need this drug often but when they did, the drug needed to be given very promptly. We advised Mrs Wallace that if this is the case, a risk assessment about this drug being kept in an un-locked cupboard is needed and an up-to-date prescription on the medicines administration record. Care Homes for Older People Page 20 of 45 Evidence: We observed that several people were prescribed medications such as painkillers or aperients on an as required basis but they did not have care plans or protocols to direct staff on indicators for their use. The use of all medicines prescribed as required must be supported by clear guidelines for staff to follow. These guidelines must indicate which medicine to use in which circumstance where a choice is available. This will ensure that people receive consistent, accurate treatment. Several people were prescribed drugs which can affect their daily lives such as mood altering drugs. Some people who had been prescribed such drugs had care plans about their behaviours, but others did not. None of the care plans that were in place referred to prescriptions for these drugs. This is advised so that the effectiveness of such medication for the person can be evaluated. Care Homes for Older People Page 21 of 45 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 will be able to exercise choice, particularly at mealtimes, however an increased emphasis placed recreational activities will ensure that risks of social isolation are reduced. Evidence: During the inspection, we discussed activities with people living in the home and received a variety of responses. One person reported someone comes and helps us do things, another that a person came into the home on Wednesday and helped them to make flower pots and do all sorts of nice things and another we get activities twice a week. Other people responded differently. One person reported on the lack of company and another that they got very, very lonely. During the inspection, we observed that residents who wished to, came down to the sitting room. Most of the time residents were sitting there watching, television or dozing. There was a family feel to the room, with residents welcoming each other and chatting as they came down from their rooms, followed by periods when the people gradually became quieter for a while. Staff came in and out of the room and always talked with residents when they were in the room, this included the cook. We observed Care Homes for Older People Page 22 of 45 Evidence: that one resident who wished to smoke was able to sit outside. They were joined for a period by a former resident, who came to chat and then later by a member of staff who also chatted with them. An activities programme was displayed in the hall-way, however it related to 30th May to 5th June, two weeks before the inspection. In the AQAA, the home reported on the Wednesday Lunch Club when involved individuals from the community dine with the residents as a social occasion. The home employs an activities coordinator on a part-time basis. They maintain their own records, separately from the care plans. These records included a risk assessment for social isolation, which is a useful approach to activities provision. All people had a risk assessment completed. Several peoples risk assessments indicated they were at high risk of social isolation. Some people had profiles of their past lives completed but not all. Several people had the importance of religion to them documented. In their AQAA, the home reported on how they identified individual needs in care plans. Some people had social care plans included in with their other care records but others did not. One person had a very detailed care plan about the impact of their family circumstances on them. Another person had a care plan about which radio station they preferred to listen to when they were in their own room and we observed that this care plan was complied with. None of the activities folders we reviewed had a care plan about how the person needed activities to be supported for them, this included people assessed as being at high risk of social isolation. All people had a record of activities participated in, including benefits for them. As different information is kept in different places, social inclusion would be supported if social assessments and care plans were all kept with residents other notes, to ensure ease of access for all staff. Additionally it is likely that carers will support residents with individual matters whilst caring for them, but all the carers daily records related to personal care interventions and did not document other ways carers may have been supporting the resident. We spoke to residents about how how they chose to spend their day. One person reported I get up when I want to, another Im in bed because Ive been quite poorly, I dont go down, prefer my own company, another they leave it up to me, I do what I want and another I stay in my room, I like to be quiet. When we started the inspection at 9:00am, we observed that only one person was in the sitting room and that other people gradually joined them during the morning. This indicates that staff were able to let residents chose when they got up and came downstairs. We observed that one frail person was allowed to continue to smoke and that staff supported them in this if they wished to do this. This factor in supporting this persons choice did not have a care plan, to ensure that they were fully supported in doing this as they wished, within the bounds of safety. This is of concern as the person was Care Homes for Older People Page 23 of 45 Evidence: observed outside at one time, wearing their night clothes and only one slipper. A review of the homes file showed that the home has worked with families, to ensure that individuals can continue to be supported by family as they wish. It also shows that the home have supported people in going out of the home to their own church. We talked to people about meals. One person reported very good I think the food steak and kidney pie - my favourite, another weve a good cook, she cooks her food lovely and another that the food was very good, if I dont like the choice, theyll try something else. We observed that residents could chose a different meal if they liked, this included a person who needed their food to be pureed. We met with the cook, who reported that as the home was so small, they were able to know peoples individual likes. They reported if food comes back I go and find out why. They reported that they cooked nearly all food up from raw ingredients, this included gravies and sauces. We observed that the cook rang a bell just before they served the meal. Residents gave all appearance of appreciating this, so that they could prepare for the meal and there was an excited conversation of there goes the dinner bell in the sitting room. Residents who ate in the sitting room were observed to sit watching the television and use tables over their chairs. One residents relative came into the home at lunchtime to assist their relative to eat their meal. We observed that the home also gave them a meal. The meal was attractively presented and looked hot. Where people needed assistance to eat, staff sat with them supporting them in eating their meal. Care Homes for Older People Page 24 of 45 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be able to raise issues of concern. Some residents may not be protected by the homes procedures to ensure that they are fully protected from risk of abuse. Evidence: The home has a complaints procedure, which is displayed in the main entrance hall. All of the people who responded in questionnaires reported that they knew how to make a complaint. One person reported that the welfare and administrative manager comes round every day and that they would report any concerns to them. This was echoed by people we spoke to. One person reported if Im not happy, Id go to [Mrs Wallace] - shes very good and another if Im not happy about something, I talk to [administrator]. However one person did report no-one to talk to or anything. We looked at the homes complaints register and observed that the home documented verbal as well as written comments. The record showed that complaints were investigated and actions taken if indicated. We noted as good practice that Mrs Wallace had recently attended up-dates on the Mental Capacity Act and risks of deprivation of liberties for frail people. She has gone on to ensure that all residents have had an assessment of risk in these areas and has set up care plans when relevant, to detail how residents are to be protected from risks and their needs met. Discussions with both Mr and Mrs Wallace showed that they have Care Homes for Older People Page 25 of 45 Evidence: referred people to advocacy services when indicated and are used to working in partnership with advocates. We are aware that the home has been the subject of two multi-agency safeguarding referrals during the past year and has also made referrals themselves in support of vulnerable people. One safeguarding referral was handed back to the home for investigation, which they did and they took relevant action in relation to any members of staff involved. This inspection shows that some areas identified during this safeguarding investigation relating to some areas of practice in to the use of drugs which had not been prescribed may continue to need action. Another multi-agency investigation is not yet fully complete. However, this inspection shows that some matters identified during the investigation relating to ensuring care plans are in place for all needs and documentation in monitoring records had not been acted upon in full by the home. We discussed a range of scenarios relating to safeguarding vulnerable adults with four members of staff. Two members of staff were very clear on their responsibilities and well aware of scenarios which could indicate that vulnerable people needed safeguarding. However two members of staff were much less aware and when thinking of factors needed much prompting to consider that certain matters could indicate that the person might be at risk of abuse. They were also not clear of actions they needed to take, in accordance with local procedures, to ensure that the person was safeguarded. In their AQAA, the home reported that their evidence to ensure that this outcome area was addressed could be identified in the staff training file. We looked at the records of staff training on abuse awareness and observed that of fourteen records reviewed, only three showed that the members of staff had been trained in abuse awareness. The person in charge of training reported that they had only taken on their role two weeks before the inspection and were aware that the previous training manager had not always up-dated records as required. Mrs Wallace reported that training in abuse awareness was planned for all staff in the home in the next few weeks. Care Homes for Older People Page 26 of 45 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. Peoples needs will be met by the home environment, however some deficits in systems to prevent spread of infection may put people at risk. Evidence: In their AQAA, the home describe how they balance a traditional house setting with modern requirements. Maristow House is a large town house set in a residential area of the city of Salisbury. The front garden has been ramped to make it wheelchair accessible. There is a garden to the rear, with a wheelchair lift so that residents who are wheelchair dependant can access the back garden. The home was not purposebuilt, so rooms are different sizes and shapes which gives each room an individual atmosphere. There is one large sitting/dining room opposite the kitchen and a smaller, quieter sitting room at the front of the building. The hall-way is domestic in style, enhancing the homely atmosphere. One resident reported that Maristow House smells like home. One of the rooms is down a flight of stairs. The person in this room remains in their room all the time. The room was large, bright and airy. As noted in Choice of Home above, one person who was admitted recently was cared for in a room up a small flight of steps. In their AQAA, the home report on new furnishings and accessories in communal areas - including artwork and lighting. The report that they have painted the entrance hall and other areas. Care Homes for Older People Page 27 of 45 Evidence: The home has a range of equipment to meet the needs of people with a disability. We observed staff competently using hoists to assist people to move. Many of the beds are profiling and the home has invested in three high tech mattresses to fully support people with very high risk of pressure ulceration. The home also has a range of other equipment including air mattresses, to support people at risk of pressure ulceration. In their AQAA, the home reported on their purchase of hoist scales to improve the monitoring of residents weight. We met with a domestic and observed them at work. This person was observed to carefully shampoo a carpet, moving items of furniture to effectively shampoo underneath them. We discussed supplies with them and they reported they had a good supply of cleaning chemicals. All of the people who responded in questionnaires reported that the home was always or usually fresh and clean. We observed that there were good supplies of disposable gloves and aprons and people were using them. Disposable gloves were available in a range of sizes. One carer reported weve a good supply of gloves. All white laundry such as sheets and towels go out to a private contractor for laundering. The home uses a red bag system for infected and potentially infected laundry. We met with a carer who was doing the laundry and they reported that staff always consistently put contaminated laundry in red bags. This person reported that as the home was so small, if any items of clothing were not marked, they usually knew who they belonged to. During the inspection, we observed two occasions when staff had been changing a residents bed linen and had placed the items on the floor of the residents room. Leaving used linen on the floor of a room may lead to contamination of the residents carpet. Staff must at all times remove used linen and place it directly into the linen skips which are provided for this purpose. We observed in the assisted bathroom there were three plastic containers with toiletries in them; all were unmarked. Additionally there was a hairbrush, which had different coloured strands of hair in it. There were two bags of clean underwear in the corner, which we were later informed belonged to a person who had died some time ago. This indicates that there are risks that people will be using such items for people that they do not belong to. Additionally, as noted in Health and Personal care above, there are a range of topical applications in residents rooms which do not belong to them. There is a known risk to cross infection presented by the communal use of creams. Such practice also does not uphold peoples privacy and dignity. We observed that there were a good supply of slings for hoists and turning sheets. None of these were named. One of the slings left in the sitting room after transferring Care Homes for Older People Page 28 of 45 Evidence: a resident to an easy chair was odorous. One of the people who needed transferring using a sling was documented as having an infection. In order to prevent risks of cross infection, slings must be labelled for individuals and used only for them. They must also be laundered regularly. One person was being cared for in a profiling bed which had been lowered to the floor with a crash mat next to it. The crash mat was not clean was was sticky on the surface. Some of the commode chairs were deteriorating in their fabric on the underside of the cushion. A toilet seat had also lost its plastic veneer and the under-surface was showing through. All such items need to be intact and wipable to prevent risks of cross infection. Some of the commode buckets had been left damp, to the extent that the liquid in them showed a yellow colour. We asked a carer how they cleaned commode buckets and were told that they were cleaned in the closest toilet to the residents room, using chemicals. We asked about a washer disinfector for sanitary items but were told that the home did not have one. Mr Wallace reported that the washer disinfector had broken down earlier in the year. He had developed an action plan for its replacement in a better area of the home and anticipated that the home would have a fully functioning washer disinfector by 31st October 2009. Until this happens, the home must ensure that commode buckets are properly cleansed after use and left dry, to prevent risks of cross-infection to residents. Care Homes for Older People Page 29 of 45 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. Peoples needs will largely be met by systems for staffing, however the home is not providing evidence that all staff are trained in meeting residents needs and that they are complying with all guidelines for recruiting staff. Evidence: In their AQAA, the home reported on its high staff to resident ratio and how this high ratio reduced stress and workload for individual staff numbers. On the day of the inspection, there were two people on duty for the night shift, a registered nurse and a carer. On the day shift, there was one registered nurse and three carers on duty. One carer was working supernumerary, as they had only just commenced working in the home. Additionally there was an administrator and the cook on duty. Both Mr and Mrs Wallace were also in the home working a management day. People commented about staffing in questionnaires. All people reported that there were always or usually staff available when they needed them. One person commented whenever [the resident] needs them they come up to help. We also talked about staffing levels with residents. As many residents had difficulties with communication, it was not an area which many people felt able to comment on. One person did report Ive got a bell and they come as soon as they can, sometimes they take a long time - cant help it - others need help too. One member of staff described Care Homes for Older People Page 30 of 45 Evidence: the work-load as heavy. During the inspection, we observed that at 10:30, there was a resident waiting to be hoisted from their wheelchair into an easy chair, they were joined shortly after by a second resident who also needed hoisting. Hoisting is a process which needs two staff to ensure safety. Both residents had to wait until after 11:00am for two members of staff to be available to hoist them to an easy chair. One resident asked more than one if they could be moved, as they were becoming uncomfortable waiting. We reviewed the files of four people who had been recently employed, a registered nurse, a carer, a member of the ancillary staff and a person from abroad. All people had police checks, two satisfactory references, a past employment history, a health status check and, where relevant, current work permit. None of the files included proof of identity, as is required to ensure that the home has full verification of who all their staff are. Staff were all interviewed using an assessment tool, to assess their suitability for their role. The new member of staff was not wearing uniform, so was easily identifiable as needing to work supervised, until their full police checks had been returned. On taking up their role, it was reported that all staff would spend two to three days with the training manager, then be teamed up with senior carer and shown their job. We reviewed one persons induction records, it included all required areas and sections were signed off as they were undertaken. The induction is set out as seven steps of values and staff work their way through them gradually. Records were maintained both as hard copies and on computer files. We met with a new carer who was on induction. They reported on how much they were enjoying their role. They also confirmed that as they had not had full manual handling training that they were not performing such roles. We observed that other staff were also aware of this and did not try to ask the person to support them in manual handling. The training manager reported that they had only taken over this role two weeks before the inspection and were in the process of reviewing staff training records. They reported that they had found some deficits in training records. For example, they had been the manual handling trainer for the home and had trained staff in the area regularly. Of the 14 staff records reviewed, only three indicated that staff had received training in the area during the past year, although the current training manager reported that they had trained far more members of staff than that number, during the past year. The home does not maintain a matrix of training undertaken so that the managers can see at a glance who has been trained in mandatory areas and who is due to be trained. The review of 14 staff training records indicated that only seven members of staff had been trained in infection control, two in food handling and three in abuse awareness. The home needs to develop clear records of training undertaken Care Homes for Older People Page 31 of 45 Evidence: so that it can evidence that staff have been trained. This is particularly necessary as this inspection showed deficits in staff awareness of some areas of prevention of spread of infection and some staff were not aware of safeguarding vulnerable people. The home manager reported that the home fully supports National Vocational Qualifications (NVQ) and that at present there were three carers undertaking NVQs at level 2. The domestic reported to us on their training and how supported they had been by the home. This person had successfully gained an NVQ 3. In their AQAA, the home reported on training in other areas, including most recently stoma care, quality assurance and winter health issues. As noted above, not all records were up-to-date and Mrs Wallace reported that there were other areas where staff had received training but had not been documented, for example training on care planning. The home cares for one person with a stoma and several people who are artificially tube fed, training records do not evidence that care staff have been trained in these areas. Mrs Wallace reported that they had trained carers in administering certain medication by an invasive route. This is acceptable but records to evidence this are needed. NMC guidelines state that when delegating any aspects of the administration of medicinal products that the registered nurse is accountable to ensure that the career is competent to carry out the task. Therefore the home needs to update its training records so that it can verify that staff have been trained in all areas to meet residents needs. Care Homes for Older People Page 32 of 45 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home home does not have full management systems in place to ensure the health, safety and welfare of people. Evidence: Maristow Houses registered manager is Mrs Lindsey Wallace. She is also the owner of the home. Mrs Wallace is an experienced registered nurse. Mrs Wallace is supported by her husband who performs some management roles in support of her. The home also employs an administrator who manages the office function and who has recently taken on management of staff training. In their AQAA, the home reported on their monthly management reviews which consider health and personal care issues. The home has just commenced systems for reviews of quality of service provision. They have set up monthly management meetings to review quality in the home, using key areas with fixed agenda items, including health and safety and matrons report. Mrs Wallace reported than one of the Care Homes for Older People Page 33 of 45 Evidence: next areas they are planning is a staff survey. Accident records are maintained, however the home do not perform written reviews of accidents, to identify any trends in accidents, such as time of day or any equipment used. The home operates a cashless system for sundries such as hairdressing and chiropody. All residents have their own individualised computer account, from which charges for additional services are made. Their designated representative is sent an account as and when indicated. We looked at systems for health and safety. We watched a registered nurse and a carer using a hoist and slings to transfer three residents. The registered nurse explained to each resident what they were going to do. Both members of staff supported the resident throughout, ensuring that the person was moved safely, with both members of staff checking with each other on safety throughout the procedure. Staff ensured that each resident was comfortable afterwards and explained what they were doing before they removed the hoist sling. We observed that two residents were moved in wheelchairs without foot-plates. This is regarded as unsafe practice, as it has the potential to cause injury to residents feet. We asked a member of staff about this. They reported that all other residents always used foot-plates but for these residents, they had damaged their heels by use of footplates. We reviewed one of these peoples care plans, which stated that they needed foot-plates on their wheelchair and that staff were to check they were on correctly. No recent record could be found in the persons records about injury or risk of injury to their heels. There was no evidence that the person had been referred to a specialist such as an occupational therapist, to identify equipment which would support them. This situation is not satisfactory and staff must either follow care plans or document why they have not and what actions have been taken to ensure the persons safety. There is a large body of evidence relating to the risks presented to people by the use of bed rails. We observed that several people had bed rails in place. Several of the beds were profiling, but only one person was observed to have their bed lowered close to the floor, with a crash mat as is advised, to prevent risks associated with the use of safety rails. One person in a profiling bed reported to us that they did not like having safety rails in place. We observed that one residents non-integral safety rails were loose in their fixings and another person had a significant gap between the end of the safety rail and the bed-head. This person also showed us that they had a wedge in their bed to stop their leg falling out of the bed and becoming wedged between the bed and the safety rail. We looked at peoples records and did not observe that assessments for bed rails were maintained in care plans. After discussion with a manager we were directed to a different folder, where bed rail assessments were maintained. We observed that most people did have assessments for the use of bed rails. The person who had bed rails in place who was using a wedge to ensure that Care Homes for Older People Page 34 of 45 Evidence: their leg did not become jammed had a care plan which stated that they did not need bed rails. The person who had a profiling bed who said that they did not like bed rails did not have a bed rail assessment. This evidence indicates that not all staff are checking the safety of bed rails as they provide care and that staff are not complying with care plans in relation to bed rails. During the inspection, we observed people coming and going into the kitchen. They did not put on aprons or coats when they went into the kitchen. When we asked the registered nurse to let us inspect the medicines cupboard, they led us through the kitchen, rather than taking us round the corridors to access the medicines room. This indicates that this is normal practice for the home. We raised this matter for clarification with the Environmental Health Department who reported that they had last inspected Maristow House on 12th May 2009 and had made the following statement in their report: Despite the provision of coffee making facilities in the corridor outside of the kitchen since the last inspection the kitchen is still widely used for a variety of food and drink purposes by non kitchen staff working on the premises. You must closely examine the use of the kitchen and do all possible to prevent the risk of contamination of the food provided for residents. Ideally access to the kitchen should be restricted to kitchen staff only, but if this is not possible you must: Reduce staff access to the kitchen to the absolute minimum during such times that food is being prepared. Ensure that staff involved in the personal care of residents wear the protective gloves and aprons provided and that they change out of them and wash their hands thoroughly before entering the kitchen. Have a contingency plan in place to prevent all non kitchen staff entering the kitchen during any outbreak of diarrhoea and/or vomiting at the premises. This item must be completed within one month. Evidence from this inspection shows that the requirements of the Environmental Health Officer have not been met within timescales. This is of concern as management has not taken actions within timescales to meet requirements set out by a statutory body. We reviewed systems for maintenance of equipment and services. There was evidence Care Homes for Older People Page 35 of 45 Evidence: that equipment such as hoists and lifts were regularly serviced. We looked at the tests on hot water temperatures in resident areas and noted that they were tested quarterly, not monthly as is advised. The fire risk assessment did not detail how evacuation procedure was to be performed and it was also not clear if staff had been trained in the use of fire extinguishers. By the second day of the inspection, a manager had obtained the latest directions on fire risk assessments and had developed a plan to up-date the homes fire risk assessment. One person had a free-standing radiator in their room. They did not have a risk assessment about this. Free-standing radiators are regarded as a risk both to fire and health and safety and their use must be avoided as much as possible. If a free-standing radiator is needed, it must only be used following a full risk assessment. Care Homes for Older People Page 36 of 45 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 37 of 45 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 12 All of a persons needs must 31/07/2009 be assessed prior to or immediately after admission. Where needs are identified, prompt action must be taken to address these needs People need full assessments so that the home can plan how to meet their needs. If a persons condition changes immediately after admission, prompt action must be taken to meet these changed needs. 2 7 12 Care plans must be reviewed 31/07/2009 on a regular basis and must always be reviewed if a persons condition changes and different interventions are indicated. If care plans are not reviewed when needed, staff will not be directed on how peoples current needs are to be met. Care Homes for Older People Page 38 of 45 3 7 12 Where a person has a need, there must always be a care plan in place. Care plans must describe how needs are to be addressed in an clear and precise manner. Care plans direct staff on how peoples needs are to be met. If care plans are not in place, residents are at risk of not having their needs met or not having them met in a consistent manner. 31/07/2009 4 8 12 Where a person has a 31/07/2009 monitoring chart, charts must provide evidence that the person is receiving the care that they need. Records must be accurate and completed at the time care was given. Monitoring charts enable staff to know what care has been provided and are particularly important where a person is unable to communicate effectively. They also enable managers to verify that care has been given as required. 5 8 13 Topical applications, swabs, syringes and other items used in medical care must not be used after their expiry date. Items used in clinical care may not be effective, may not work in the manner anticipated and may present 31/07/2009 Care Homes for Older People Page 39 of 45 a risk of infection if they are used after their expiry date. 6 8 13 The use of all medicines 31/07/2009 prescribed as required must be supported by clear guidelines for staff to follow. These guidelines must indicate which medicine to use in which circumstance where a choice is available. This will ensure that people receive consistent, accurate treatment. 7 9 13 All prescribed medication 31/07/2009 must be labelled and only administered to, or used for, the named person. This will ensure that all people receive the correct treatment. 8 9 13 Only medication that is in current use must be kept in the home. Medicines no longer required must be sent for destruction. This will ensure that people are not at risk of using incorrect medication. 9 9 13 Controlled Drugs must only 20/07/2009 be adminstered for the person for whom they have been prescribed. Any known discrepancies must be fully documented in the Contolled Drugs Register. By their nature and risk to people, there are clear guidelines about the prescription and use of 31/07/2009 Care Homes for Older People Page 40 of 45 Controlled Drugs. To prevent risk to people, these gudielines must always be adhered to. 10 9 13 If a drug needed in an 10/08/2009 emergency is kept in an unlocked cupboard, there must be a risk assessment drawn up. If drugs are kept unsecred, this could present a risk in a care home environment. Therefore a risk assessment must be in place to ensure that risk to people is reduced to a minimum. 11 9 13 A person must not be administered a drug unless it has been prescribed for them. If a person is given a drug which a GP has not prescribed, the person may be put at risk. 12 12 15 All residents must have a 31/07/2009 plan drawn up to direct how their social care needs are to be met. Residents social care needs are an important area of care, particularly if the person is at risk of social isolation or has dementia or a dual diagnosis. 13 18 13 The home must ensure that it has robust systems, including staff training, to ensure that vulnerable people are safeguarded. 31/07/2009 31/07/2009 Care Homes for Older People Page 41 of 45 The home cares for some very frail and vulnerable people who need protection across a wide range of areas. Therefore the home must have full systems in place to ensure that such people are protected. 14 30 18 The home must ensure that they are able to demonstrate that all staff have been trained to meet residents needs, including mandatory areas. If the home does not maintain records of staff training, management cannot ensure that all staff have been fully trained to meet residents diverse needs. 15 29 19 The home must ensure that they can have verified a persons identity. Proof of a member of staffs identity is a key area in safe recruitment. 16 26 13 All commode buckets must 31/08/2009 be fully cleaned and dried after use. All sanitary facillities such as toilet seats and commode chairs must have intact surfaces. Micro-organisms can grow in unclean or damp sanitary equipment. If sanitary equipment cannot be wiped down effectviely, they can harbour micro-organisms. 31/07/2009 31/07/2009 Care Homes for Older People Page 42 of 45 17 26 13 Systems must be put in place to ensure that hoist slings, residents personal items, including topical creams, are not used communnally. Communal use of hoist slings and personal items presents a risk to cross infection, so all such items must be named for the person and be used only for them. 31/07/2009 18 31 16 The management must ensure that it complies in full with directives from external statutory bodies. External statutory bodies make requirements to ensure the safety of people. Therefore their directives must be complied with within their set timescales. 31/07/2009 19 38 13 All matters which could have 31/07/2009 the potential to affect the health and safety of residents must be documented, together with actions taken to address the matter. A range of matters may affect the health and safety of people, therefore documentation about such matters must be in place. 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 Care Homes for Older People Page 43 of 45 improving their service. No. Refer to Standard Good Practice Recommendations 1 2 7 7 Care plans relating to continence should state all interventions needed by the person. Care plans should always use clear, precise measurable language, wording such as creams, normal parameters, regularly should be avoided. Care plans relating to urinary catheters should always state the clinical reason for use of the catheter. Food charts should state what diet a person has taken, rather than puree. Residents GPs should be approached to reduce the numbers of drugs prescribed for 6:00am. Where a person is prescribed a drug which can affect their daily lives, this should be included in their care plan, so that evaluation of the effectiveness of the treatment can be assessed. Carers should have ready access to social care assessments, care plans and records. All residents should have a full personal profile drawn up of their past lives and interests. When carers document in their daily records they should include social interventions as well as how they have addressed the persons physical care needs. The home should develop a matrix of staff training. The home should review if they have sufficient staff on duty at all times of the day. All crash mats should be regularly cleaned. Accidents should be regularly reviewed in writing to identify any trends. Hot water temperatures should be checked at least once a month. Staff should have ready access to risk assessments and care plans relating to health and safety issues. 3 4 5 6 8 8 9 9 7 8 9 12 12 12 10 11 12 13 14 15 30 27 26 38 38 38 Care Homes for Older People Page 44 of 45 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. 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