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Inspection on 25/11/09 for Maristow House Nursing Home

Also see our care home review for Maristow House Nursing Home for more information

This inspection was carried out on 25th November 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Maristow House is a small nursing home so residents, visitors and staff can get to know each other well. The house is a large town house, not a purpose-built building, this gives the home a family feel. As it was not purpose-built, all the rooms are different from each other, making it easier for residents to personalise their own areas. The management of the home are flexible and open to change. Since the last inspection, managers have acted to put in a wide range of improvements in service provision. The cook and activities coordinator both knew all the residents well and were keen to provide an individual service to meet peoples` diverse needs. People expressed their appreciation of the service. One person reported "the home is like one happy family", another "it`s a very good place" and another "I`m very happy here." People commented on the staff. One person reported "I have great confidence in the staff", another that the home showed "careful consideration of individuals needs" and another that the home provides "a excellent personal service".

What has improved since the last inspection?

At the last inspection, the home was assessed as providing poor outcomes to residents. Management have put in a wide range of improvements so that, within four months of the last inspection, they are now judged as providing adequate outcomes for residents, with five outcome areas judged as being good. The home has made major improvements in medicines administration and recordkeeping. Residents are now only administered medication if it is prescribed for them. The practice of prescribed medicines being used for other residents and use of out of date medicines has been very much reduced. Records relating to controlled drugs have improved. Where medicines needed in an emergency are stored in residents room, there is now safe documentation and practice relating to this. Systems for sending medicines for destruction where they are no longer in current use, have improved. The home has documentation to ensure that "as required" medication is given in a consistent manner. Systems for pre-admission assessment and care planning have been progressed. This includes revised pre-admission assessments, which are much more individual in tone, providing evidence that the home can meet people`s individual assessed needs. Improvements have been made in assessments and care plans for people in the home, with records being more individualised and relating to the resident, setting out how their individual needs are to be met. The home has improved record-keeping for frail people who need supports in moving themselves or eating and drinking. Activities care plans have been much developed so they can demonstrate how residents` recreational needs can be met. Attention has been made to improvements in cleanliness of items such as commodes and crash mats. Bathrooms are no longer being used to store residents` personal items, including items for people no longer in the home. Used laundry is now managed appropriately. Major improvements have been made in training. A full training matrix has been put in place and the home can now demonstrate that all staff have been trained in mandatory areas. Safeguarding training has taken place and staff spoken with understood their role in safeguarding people. Training in other areas to support people has been progressed, for example dementia and palliative care. The home has developed its approach to health and safety, in accordance with advice from statutory bodies. Systems have been put in place to ensure that the kitchen is not used as a passage-way. The home has reduced its use of safety rails as much as possible, in line with current guidelines. Developments have been made in records relating to safety checks such as records of hot water temperatures. The fire risk assessment is being progressed in line with recommendations from the fire brigade.

What the care home could do better:

The home needs to continue its developments in care planning. At the time of the inspection, only one resident had a full, individualised care plan relating to their personal needs. The home are planning to develop similar plans for all residents. At present not all care plans to meet needs are in place, some care plans were not being regularly evaluated and staff were not always following care plans. Provision of care to people at high risk of pressure ulceration needed some improvements, to take current research-based evidence into account. The home have put many improvements in to medicines management, however there continued to be some items which were prescribed for other people in use by different residents some items which were not named and some out of date items being used. The clinical rooms needs tidying up to prevent overstocking. The home needs to continue to show that peoples` health and safety needs are being met, including appropriate assessments and ensuring that staff follow care plans to ensure residents` safety. Care plans relating to manual handling need to fully reflect the resident`s needs, to ensure the safety of both resident and staff. Staff recruitment records need to be audited to ensure that they include all relevant pre-employment checks. This will ensure that residents are not put at risk of being cared for by staff who have not been fully vetted prior to offering employment.

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:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 2 6 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 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: Mrs Lindsey Jayne Wallace care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: 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, Wiltshire and 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 Care Homes for Older People Page 4 of 32 Over 65 17 0 2 0 17 2 0 9 0 7 2 0 0 9 Brief description of the care home home is privately owned by Mrs Lindsey Wallace who is also the registered manager. 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 32 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: As part of the inspection, 30 questionnaires were sent out and six 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 reviewed and information obtained since the previous inspection considered. Since the last inspection, we have received a detailed improvement plan from the home. This is their plan for how improvements were to be made in service provision. We looked at the improvement plan, 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 doing the inspection. The site visit was performed by two inspectors, one of whom was a pharmacist inspector. These people are referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The site visit was on Wednesday 25th November 2009, between 9:05am and 4:30pm. The visit was Care Homes for Older People Page 6 of 32 unannounced. A registered nurse was in charge of the home when we commenced our visit and the manager, Mrs Wallace came on duty during the morning. Mrs Wallace, Mr Wallace and the administrator were available for the feedback at the end of the inspection. During the site visits, we met with five residents and observed care for two 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 three 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 a registered nurse, two carers, the administrator/training manager, the activities coordinator and the cook. 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. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? At the last inspection, the home was assessed as providing poor outcomes to residents. Management have put in a wide range of improvements so that, within four months of the last inspection, they are now judged as providing adequate outcomes for residents, with five outcome areas judged as being good. The home has made major improvements in medicines administration and recordkeeping. Residents are now only administered medication if it is prescribed for them. The practice of prescribed medicines being used for other residents and use of out of date medicines has been very much reduced. Records relating to controlled drugs have improved. Where medicines needed in an emergency are stored in residents room, there is now safe documentation and practice relating to this. Systems for sending medicines for destruction where they are no longer in current use, have improved. The home has documentation to ensure that as required medication is given in a consistent manner. Systems for pre-admission assessment and care planning have been progressed. This includes revised pre-admission assessments, which are much more individual in tone, providing evidence that the home can meet peoples individual assessed needs. Improvements have been made in assessments and care plans for people in the home, with records being more individualised and relating to the resident, setting out how their individual needs are to be met. The home has improved record-keeping for frail people who need supports in moving themselves or eating and drinking. Activities care plans have been much developed so they can demonstrate how residents recreational needs can be met. Attention has been made to improvements in cleanliness of items such as commodes and crash mats. Bathrooms are no longer being used to store residents personal items, including items for people no longer in the home. Used laundry is now managed appropriately. Major improvements have been made in training. A full training matrix has been put in place and the home can now demonstrate that all staff have been trained in mandatory Care Homes for Older People Page 8 of 32 areas. Safeguarding training has taken place and staff spoken with understood their role in safeguarding people. Training in other areas to support people has been progressed, for example dementia and palliative care. The home has developed its approach to health and safety, in accordance with advice from statutory bodies. Systems have been put in place to ensure that the kitchen is not used as a passage-way. The home has reduced its use of safety rails as much as possible, in line with current guidelines. Developments have been made in records relating to safety checks such as records of hot water temperatures. The fire risk assessment is being progressed in line with recommendations from the fire brigade. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The improved systems for admission to the home mean that residents needs will be fully assessed prior to and at admission. Evidence: The home have introduced a new assessment system for people prior to admission. The new system is much more comprehensive and detailed than the homes previous system. Only one person had been admitted since the previous inspection, however if the new systems reviewed at this inspecting continue for all residents, the home will be fully meeting or even exceeding current standards in the future. We met with the one recently admitted resident, discussed their needs with staff and reviewed their records. The new resident had complex needs and was not able to inform us much about their admission process to the home. Staff informed us that the residents family had been closely involved in decisions about admission to the home, in support of the resident. Care Homes for Older People Page 11 of 32 Evidence: A review of this persons records showed that their needs had been considered in detail prior to their admission to the home. For example, a detailed record of their dietary preferences and how they needed to be assisted to eat was included in their admission documentation. The home had also ensured that a full record of the persons history of a need for a specific prescribed appliance was documented in detail. The activities person reported that they had met with the person and was developing a plan as to how they would be supported. Since the persons admission, the home had been trying a different aid to support the person in mobility. Records and discussions with staff showed that this had supported the person in regaining some self-care skills. There was also evidence that the home had ensured that the person had been assessed by two external health care professionals since their admission, to improve specific aspects of their more complex needs. The cook reported to us that they tried to meet with people or their relatives before their admission to the home, so that they could start discussing their likes and preferences for meals. The activities person reported that they were always told about planned admissions, so that they could start looking at the persons preferences for activities. Care Homes for Older People Page 12 of 32 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. Residents will have improved outcomes, as systems are in the process of being developed to ensure that the home can meet their individual health and personal care needs. Evidence: At the previous inspection, this outcome area was judged to be poor. The home have made much effort into improving outcomes to residents in this key area. This includes developing new record-keeping systems, staff training on meeting residents needs and improved systems for management of medication. People expressed their appreciation of care provided. One person reported its a very good place, another I get quite a lot of good attention and another I do fairly well here. A person was aware of a range of interventions that they needed from staff and was able to describe how the staff met their individual needs. Another person reported that they liked being supported in maintaining their own independence as much as possible by staff, reporting I help myself as much as I can. Care Homes for Older People Page 13 of 32 Evidence: We met with people with a range of different nursing and care needs and reviewed their records. As would be anticipated where a home is introducing revised systems, some records were clearer than others. For example, one persons records showed that they had anxious behaviours, which we observed and staff reported to us how this affected the person. This persons records showed how these anxious behaviours affected their daily life and there was a clear development plan in the persons records about how staff were planning to build a trusting relationship to support the resident. The persons records clearly stated progress achieved since the plan was developed. The persons records about this need were written in a supportive, non-judgemental manner. For most of the residents, their needs were documented in the homes previous systems. Some of these records were very clear. For example one resident had a detailed care plan about their complex communication needs and another person about their care needs at night. One person had a clear wound care plan, another person had a detailed care plan put in place when they developed an infection and another person had a clear care plan about a urinary catheter, including when they needed the catheter changing, how their personal care was to be managed in the light of this catheter and how often the drainage bag needed to be changed. Other records were not so clear. One persons records relating to their bowel care needs, including the use of suppositories were unclear, with different records in different places, some of them conflicting with each other, so it was not possible to assess if the persons needs were being met or not. Another person had conflicting records relating to an intervention for their urinary catheter so it was not clear when interventions had occurred or why they were being performed. Care plans and records relating to nursing and care need to be clear to enable full assessment of need and identify actions needed to be taken by staff. It is anticipated that where residents have a need or a risk, that their care plans will be regularly evaluated, generally on a monthly basis. Reviews of records indicated that this was not taking place for all residents. One person had not had formal review of their care plans for a period of three months, the plans were then evaluated, but the following month there were again no reviews of their needs. Observations showed that staff were not following one persons care plan. It was reported that this was because the persons needs were changing and so staff could not follow what was directed in the persons care plan. The persons care plan had not been revised to reflect their changing needs. Some records needed more clarity. Many of the residents were assessed as being at high risk of pressure ulceration. They were provided with appropriate pressure Care Homes for Older People Page 14 of 32 Evidence: relieving equipment when they were in bed but when they were sitting out, they were provided with an aid which related to a lower degree of risk. As risk of pressure ulceration does not decrease when a person is sitting out in a chair, the reasons as to why a lower specification pressure relieving aid is to be used needs to be documented. Where a person was cared for in bed, there were clear systems to ensure that their positions where changed regularly to reduce risk of pressure ulceration, however when a person was cared for out of bed for much of the day, records did not show that the person had had their position changed. Staff reported that this did take place but there was no evidence to show that the person had had their position changed at the frequency indicated by their assessed degree of risk. One persons daily record indicated that they could become sore on a pressure point at times but a care plan to address this need had not been put in place. Where people needed assistance with drinking or eating their meals, assessments were made and care plans put in place. Where such people needed to have their fluid and or dietary intake measured, records were completed in full. We discussed that there were some residents who needed thickened fluids, to enable them to swallow safely. Where this is the case, as thickening agent works differently according to the type and temperature of the drink, the home are advised that they use standard phrases to describe the consistency of liquid needed such as syrup/custard/jelly to clearly instruct staff on the consistency needed in peoples drinks. Mrs Wallace reported that they had fully revised documentation for one resident and following this, were planning to perform full reviews for all residents, to ensure that they were effectively assessing, planning and evaluating needs for all the residents. They planned that this would be completed by the end of January 2010. Once this has been achieved, if care plans are completed to the same standard and the one already completed, the home will be able to demonstrate that they are meeting residents needs in a planned manner. Two of the staff commented in surveys about the additional responsibilities given to them for documentation on residents needs, reporting that they felt it took them away from caring for residents. None of the staff we met during the inspection with reported similar attitudes about the lack of benefit of documentation. Results from staff surveys may indicate that a few staff need more support in understanding the importance of accurate assessment and planning to ensure they can meet frail peoples individual needs. All personal care was provided behind closed doors. Frail people who were cared for in bed had clean finger-nails and mouths. People who spent their time in sitting rooms Care Homes for Older People Page 15 of 32 Evidence: were attractively presented. Staff were observed to ensure that when they were using a hoist that people remained fully covered during the procedure. The new recordkeeping system will ensure that residents are consulted about their preference for sex of a carer. Staff reported and records showed that the home had good working relationships with external health care professionals, including GPs. One persons records showed that the home had requested support from the continence nurse and another from the community physiotherapist. The home regularly consults with the tissue viability nurse and maintains clear wound care plans. The home do not yet perform standard assessment records for wounds responses to treatment. Mrs Wallace reported that this will be included in the new record-keeping systems. Our pharmacist inspector looked at all the arrangements for handling of medicines. There have been many improvements since the last inspection. Clear guidelines are available for the use of laxatives so that all nurses can follow a consistent approach. Care plans cover the use of medicines, including medicines prescribed when required. Medication administration records were completed accurately, and at the time of administration. The medicine round was completed in a manner that showed good practice and consideration for different peoples needs. Staff we spoke to were knowledgeable about peoples medicines and their individual situations. The record for thickeners for peoples drinks was completed at the medicine round whereas it was used at different times of day, therefore a record with the fluid chart would be more appropriate. A bladder wash out had been used, but this was not recorded on the administration record. Creams that were in use were stored in peoples rooms. A few of these had not been named. We found two items that were out of date; one which was excess stock, but one which was in use. We found two occasions when prescribed creams were in rooms other than the person the cream had been prescribed for. However this represents a much improved situation from the last inspection. All medicines were stored securely and the controlled drugs records were correct, one accounting error was corrected at the time of the inspection. A new controlled drug book was in use; however the stock levels in the old book had not been signed off as they were carried over. The homes clinical room shows a wide range of different items and appeared to be overstocked for the size and type of home. The external coverings for a few of these items had become damaged. Where over-stocking occurs, there is a risk that items will go out of date or become unsterile. Care Homes for Older People Page 16 of 32 Evidence: This outcome shows a marked improvement from the last inspection where a range of practice was noted which was unsafe and could have put residents at risk. It is appreciated that parts of one requirement from the last inspection had not been fully addressed, however considering the improvements that have been made, it is anticipated that it will be addressed in full by the next inspection. Care Homes for Older People Page 17 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported in exercising their individual likes and preferences, including at mealtimes. Evidence: Maristow is a small home and so staff can get to know residents as individuals. They employ a person to support residents in diversional activities on a part-time basis. People commented on this part of the service. One person reported they treat [my relative] as an individual and respond/stimulate [my relative] as appropriate. A relative commented particularly on the activities provision for residents and one relative commented on how much they appreciated the home having a dog. People commented on how they were allowed to chose how they spent their day. One person reported Im comfortable in bed, I dont get up if I dont want to and another sometimes I want to be alone and they let me. We met with a resident who did not want to talk to us and discussed their needs with staff. Staff knew about this persons preference for not mixing and were able to describe how they would leave the person for a period when they refused personal care, returning later to find out it the person wished to receive care. Care Homes for Older People Page 18 of 32 Evidence: All of the residents now have an individual activities plans which had been drawn up with them or their relatives. These plans describe key areas for the person from their past lives and what they want to do, or are able to do, in the home. One persons care plan described the importance to them of always having their knitting with them and we observed that staff ensured that when the person moved into the sitting room that they were given their knitting. We met with the activities person. They reported that as the home was small, they were able to provide individual as well as group activities. They described a resident who had very limited communication and how from discussing about the persons past life with family and friends, they had been able to find out that the person had liked reading and the type of books they liked, so they now would sit with the person, reading to them what the person had liked. They showed us pictures taken of entertainers who had come in to the home, which the residents who attended had clearly enjoyed. The activities person reported that they had found training in dementia of particular importance for their role and were able to describe the supports they had to meet the needs of people with dementia. The activities person knew how to support residents who had religious needs and about the availability of local clergy and religious services. Many people commented on the meals. One person reported that the food was very good, a relative reported that meals were nicely presented and a resident commented enjoy my food, it nice and hot - they know I like it like that. We observed that there was a family atmosphere in the sitting room at the meal-time, with residents clearly enjoying their meal and regarding it as an opportunity to chat together. Where residents ate their meal in their own room, they were given their main meal and when they had finished, they were served with their dessert, rather than taking both up together so the person had a cold dessert. We met with the cook who showed a good understanding of residents and their needs. They reported that they cooked most meals up from raw ingredients, including soups. The cook was able to provide individual meals where residents did not like the main meal. For example on the previous Friday, they reported that one resident did not like fish and chips so they made them a fish pie, which they did like. Many of the residents were frail and needed their meals pureeing. We met with one resident who was fully aware of why they needed a pureed meal to enable them to swallow safely. Where a resident needed assistance to eat their meal, a member of staff sat with them, supporting and encouraging them. Where a person was artificially fed, there were clear records relating to this. Care Homes for Older People Page 19 of 32 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. Residents will have their complaints and concerns listened to and acted upon and they will be safeguarded from abuse. Evidence: At the last inspection, which took place on 9th July 2009, outcome areas relating to complaints were met, with residents reporting that they knew how to raise complaints and felt assured that they would be listened to. Results of surveys indicated that by this inspection, four months later, this outcome area showed the same standards. One person commented I find management very supportive if I have any problems. At the last inspection, we reviewed records relating to complaints received by the home and found that the home documented verbal as well as written comments. The record showed that complaints were investigated and actions taken if indicated. There was no evidence to indicate that the homes practice in relation to the documentation and investigation of complaints had changed since the last inspection. Since the last inspection, the home have ensured that all staff have been trained in safeguarding people. We discussed safeguarding with the senior registered nurse on duty, who showed a good understanding of their role and responsibilities in the event of a safeguarding issue being identified. The activities person was also aware that residents might be more likely to disclose matters to them, as they were not part of the nursing and caring staff. They were aware of their responsibilities for safeguarding Care Homes for Older People Page 20 of 32 Evidence: people and understood the importance of whistle-blowing. The home has worked to ensure that people with complex clinical needs have these met, including improved documentation systems. Mrs Wallace has worked with external statutory agencies to ensure that one resident was in the process of having a formal advocate appointed to support them. Mrs Wallace was also fully aware of recent legislation in relation to the Mental Capacity Act and ensuring that vulnerable people are not deprived of their liberties. However issues were identified in relation to recruitment of staff and the home cannot demonstrate that full pre-employment checks have been carried out on all staff. Pre-employment checks are needed to ensure that staff working in the home are safe to care for vulnerable adults. Care Homes for Older People Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by a home environment which meets their needs and where the principals of infection control are largely up-held. Evidence: 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 purpose built, 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 relative stated the home is as it stays an alternative to [my relatives] own home. It benefits from being small. The provider continues to invest in the home environment. Several of the rooms were being re-decorated at the time of the inspection. A new sluice room was in the process of being installed. The resident whose room was opposite the new sluice room had been given the opportunity of moving rooms, so as not to be disturbed, however they reported that they enjoyed watching the work progressing and chatting to the workman. Care Homes for Older People Page 22 of 32 Evidence: The home environment was clean. The assisted bathroom on the ground floor was much more tidy and did not contain any older items belonging to people who no longer lived in the home. Items such as commode chairs and crash mats were all clean. As noted above, the number of creams and lotions either un-named or being used by a person with a name other than that on the prescribers label, had been very much reduced. Such practice can mean that topical creams may be used communally, which is a risk to cross infection. Staff showed safe practice in the management of potentially infected and used laundry. The laundry floor was dusty in places and washing powder was also visible on the floor in places. Systems should be put in place to ensure that all dust and powder is vacuumed up regularly. There was a ready supply of disposable gloves and aprons in the home, including different sizes of gloves to suit people with different sized hands, and latex-free gloves for people with an allergy. Residents who need to be moved using a hoist or slide sheet now have their own aid provided in their room and communal use of such aids has ceased. One resident had a nebuliser which was reported to be used occasionally. The tubing and chamber for the nebuilsed drug were clean but the mask was not. Where a person may use such equipment, there need to be systems in place to ensure that all parts of the equipment is clean, to prevent risk of re-infection for the resident. Care Homes for Older People Page 23 of 32 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. Residents needs will be met by a committed group of staff, who are well trained. Deficits in documentation relating to recruitment means that the home cannot fully demonstrate that they are protecting resident with safe systems pre-employment checks for staff. Evidence: People described the supports given to them by the staff. One person reported all the care workers and extremely friendly and another described the good, experienced, committed carers. We observed that staff responded quickly when call bells were used. On one occasion we observed staff took only 15 seconds to attend when a resident used their call bell. We reviewed the off-duty and observed that the home always had a registered nurse on duty throughout the 24 hour period. This registered nurse was supported by care assistants, with three care assistants being on duty during the morning period when we inspected. The off-duty did show one recent occasion when, due to sickness, the home had worked on lower numbers. Staff were able to describe how they had worked together to meet peoples needs when this happened. The off-duty showed that the home used agency staff occasionally but that this was kept to a minimum as much as possible. The home employs a cleaner, cook, activities coordinator and administrator as well nursing and care staff. We looked at systems for recruitment of staff. A review of three staff files indicated Care Homes for Older People Page 24 of 32 Evidence: that one person only had one reference on file and two did not have a full proof of identity, including a photograph. All staff did have police checks and a health declaration. An interview assessment record had been introduced to assess staffs suitability for their role. The home sometimes, but not always, performs a written risk assessment if issues are identified on police checks. We discussed our findings with managers who reported that they had been concentrating on ensuring that other areas identified at the last inspection had been addressed and that some documents may have not been correctly filed in staff records. We stated that all staff files must be fully reviewed to ensure that all necessary pre-employment documentation is in place. When the home used agency staff, they retained records of evidence that the agency workers employer had performed all required employment checks. We reviewed training and induction records and observed a marked improvement. The training manager had only recently been in post at the last inspection and had identified a range of deficits in training. They had worked hard to fully develop this area and there was now full evidence of training in staff in mandatory areas, including manual handling, infection control and fire safety. Additional training has been provided for staff in areas such as dementia care, palliative care and pain management. Staff inductions comply with current guidelines. National Vocational Qualifications for care staff are supported by the provider. We discussed inductions for agency staff and advised that a brief induction needs to be drawn up relating to matters local to the home, for areas such as fire and completion of residents records. Both the person in charge of the home and agency worker should sign such induction records. This is to ensure that new agency staff are fully informed of their roles and responsibilities. Care Homes for Older People Page 25 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved management systems will ensure the health, safety and welfare of residents in most areas. Evidence: At the last inspection, this home was rated as having poor outcomes for residents. Since that inspection, the management team has put extensive efforts into improving and further developing service provision. A few areas remain to be addressed but the improvements achieved within four months are clear. People commented on the management systems. One relative commented on the good leadership and management and a member of staff commented as a member of staff I feel the management are very supportive to me. The home is owned and managed by Mrs Wallace, who is an experienced registered nurse. Mrs Wallace is supported by her husband and a senior administrator. A board of directors has been set up. The board hold regular monthly reviews of service provision and makes decisions about developments needed. At the last inspection, there were Care Homes for Older People Page 26 of 32 Evidence: clear systems for management of residents moneys, including a cashless system for sundries such as hairdressing and chiropody. All residents had their own individualised computer account, from which charges for additional services are made. Their designated representative was sent an account as and when indicated. No changes have been made in these systems since the last inspection. There were clear systems for ensuring that equipment such as hoists were regularly serviced. The homes fire risk assessment was being fully reviewed and developed. There were systems in place for the regular checking of hot water outlets in shower and bathrooms to prevent risk of scalding injury to residents. Since the last inspection, the home have reduced the use of safety rails as much as possible, to minimise risk to residents from the use of such aids. We observed staff performing safe manual handling practice. For one resident their care plan relating to manual handling did not reflect what we observed or numbers of staff reported needed to assist them at certain times. Manual handling care plans need to be clear and fully reflect the situation for the resident. At the last inspection, we observed a resident being moved in a wheelchair without the use of foot-plates. This has been identified as presenting a risk of foot injury to people. We identified then that their care plan stated that the person needed foot plates on their wheelchair. At this inspection, we again observed the same resident being moved without foot-plates on their wheelchair. We discussed the matter in detail and it appeared that staff were not following the care plan as the persons wheelchair was not fully suitable for their individual needs. We stated that a re-assessment of the persons seating needs was indicated, rather than using unsafe practice. Decisions about how the person is to be moved safely also needs to be documented, until a seating assessment has occurred. The home completes clear accident records. Mrs Wallace reported that accidents are reviewed during monthly board meetings to identify any trends. The home do not perform 24/48 hour follow-up reviews when a person sustains an accident and they were advised that this should take place, as on occasion some injuries following an accident take some time to become apparent. Care Homes for Older People Page 27 of 32 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 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 All residents must have full individualised care plans. These must be regularly evaluated. Care plans ensure that people have their needs met and in a consistent manner. 29/01/2010 2 8 12 Where a person is at risk or shows evidence of pressure ulceration, a care plan must be developed. Records of changes of position to prevent risk of pressure ulceration must be made when a person being cared for sits out of bed most of the day. Risk of pressure ulceration can affect a persons health and well-being, therefore full care plans are needed to ensure that risk of pressure damage is reduced. Risks do not change when someone sits out of bed, therefore 15/01/2010 Care Homes for Older People Page 29 of 32 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 documentary systems are needed to show that the person is receiving the care that they need. 3 9 13 All topical applications that 29/01/2010 are used in the home must be clearly marked with the persons name and used only for that person. Out of date items must not be used. This will ensure that there is no risk of cross infection by a cream being used for more than one person or out of date items being used. Staff files must be audited and any deficiencies in documentation relating to the recruitment process be rectified. Staff files need to include all relevant pre-employment checks, to ensure that only who are people suitable to work in the home are employed. 5 38 13 Where practice or equipment 29/01/2010 has the potential to present a risk a resident, relevant action must be taken to prevent risk of injury. This must be supported by documentation. 29/01/2010 4 29 19 Care Homes for Older People Page 30 of 32 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 Staff need to be able to take action to prevent risk to residents. Staff need to be fully directed by documentation in how to do this. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Where a person needs fluids thickening to enable them to swallow safely, care plans should document how thick a persons fluids need to be. If different specification pressure releiving equipment is provided on a persons bed to their chair, the reasons why this is in their best interests should be doucmented in their care plan. Controlled drug records transfered to another book should be completed and a zero stock balance left. Consideration should be given to the best way to record the use of prescribed food and drink items. Systems should be put in place to ensure that the laundry floor is regularly vacuumed, to remove dust and powder. Systems should be put in place to ensure that oxygen masks, tubing and nebuliser chambers are cleaned as needed. If issues are identified on a member of staffs criminal records assessment, a written risk assessment relating to their employment should be completed on every occasion. An agency induction record should be put in place, which all relevant parties date and sign. Accidents to residents should be reviewed in writing at 24 and 48 hours after the accident. 2 8 3 4 5 6 9 9 26 26 7 29 8 9 30 38 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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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