Inspection on 06/10/09 for Marple Dale Hall Nursing Home

This inspection was carried out on 6th October 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marple Dale Hall Nursing Home 04/12/08

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

Key inspection report Care homes for older people Name: Address: Marple Dale Hall Nursing Home Dale Road Marple Stockport Cheshire SK6 6NN     The quality rating for this care home is:   two star good 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: Fiona Bryan     Date: 0 8 1 0 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: Marple Dale Hall Nursing Home Dale Road Marple Stockport Cheshire SK6 6NN 01614490771 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.barchester.com/oulton Barchester Healthcare Homes Ltd Name of registered manager (if applicable) Mr Joshua Henley-Adams Type of registration: Number of places registered: care home 86 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability old age, not falling within any other category physical disability Additional conditions: A minimum of four registered nurses must be provided between 8:00am and 10:00pm each day including weekends when 69 service users or more who require care are accommodated. A minimum of three Registered Nurses must be provided between 10:00pm and 8:00am when 69 service users or more who require nursing care are accommodated. A minimum of two Registered Nurses must be provided between 10:00pm and 8:00am each day. Ensure that three separate units for YPD each containing ten beds (30 in total) in line with National Minimum Standards are provided by May 2006. Ensure that two separate units for residential and nursing care each containing 45 beds Care Homes for Older People Page 4 of 32 Over 65 0 67 0 2 0 25 (90 in total) in line with National Minimum Standards are provided by May 2006. No more than 71 service users may be admitted into the establishment who require nursing care. Date of last inspection Brief description of the care home Marple Dale Hall Nursing Home is a care home that provides 24 hour nursing care and accommodation to 86 people. The home is split into three separate units, the Main Hall, the Balmoral Unit and Clarence House. Marple Dale Hall nursing home is owned by Barchester Healthcare Homes Limited and they also own another home on the same site called The New Windsor nursing home. The two homes have the same manager and the policies, procedures and organisational records and paperwork within the two homes are the same. Clarence House offers a specialised service to three residents with a history of brain injury. The Main Hall and Balmoral units offer nursing care and personal care for people. Marple Dale Hall is situated on Dale Road, a quiet leafy residential road approximately half a mile from Rose Hill railway station in Marple. Local bus services and shops are also available fairly close by.A long driveway leads to a car park and the different entrances to each of the suites can be accessed from here. The home has accessible garden areas and patios, which are bordered by woodlands and open countryside. Assisted bathing facilities are available throughout the home.There are a selection of lounges and dining rooms. The current weekly fees start from £327 upwards depending on the package of care required. Further details regarding fees are available from the manager. Additional charges may also be made for hairdressing, chiropody and other personal requirements. 0 5 1 2 2 0 0 8 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection, which included a visit to the home took place over 2 days on Tuesday 6th October and Thursday 8th October 2009. The staff at the home did not know that this visit was going to take place. All the key standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people that live at the home, visitors, the manager and other members of the staff team. Key standards refers to those standards we feel are particularly important in ensuring the health, safety, welfare and quality of life of people living at the home. The care and services provided to four people were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and care records was examined, including medication records, Care Homes for Older People Page 6 of 32 training records and staff duty rotas. Before the inspection, we asked for surveys to be sent out to people living at the home and staff asking what they thought about care at the home. No staff returned surveys but 10 people living at the home did. We also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. The manager completed the form well and showed that he was able to identify the areas where the service could be developed. 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 key inspection we made one requirement and 8 recommendations. At this inspection we saw that the requirement about how medicines were managed had been met and that systems for the management of medicines ensured the safety of people living at the home. Six of the 8 recommendations had been acted on. People told us that the food provided at the home had recently improved. At the time of our inspection the kitchen was being refurbished and we were told that once the work was completed new menus would be introduced with more choice and changes would be made to the roles of the ancillary staff which would give carers more time to devote to solely delivering personal care, so we could see that these changes would greatly benefit the people living at the home. At the last inspection people told us they did not feel their views were listened to and many people said they did not know or had minimal contact with the manager. Since Care Homes for Older People Page 8 of 32 then the manager has started to hold weekly surgeries and encourages people to come and discuss any concerns and give their views about the home. The management team are collectively spending more time around and about the home so they can support staff and see at first hand how the home is running. Recruitment had been given a high priority and the manager had looked at the skills and experience of the staff team to try to make sure that staff got the support and supervision they needed to carry out their role properly. On the first day of our inspection the Home Trainer was working with a carer, giving them practical advice and instruction. Being taught by an experienced person means staff get a better understanding of how to give a good standard of care and what is expected of them. Since the last inspection there have been 2 investigations to safeguard people living at the home from possible risk of harm. One investigation was initiated by the manager as there were concerns about the practices of an agency carer that had worked at the home. The second investigation found that poor record keeping meant staff could not clearly demonstrate what care had been provided to the person. The manager and staff were willing to listen and cooperate with the investigation and implemented an action plan to address the findings, which included providing further staff training. The Home Trainer had improved the records of staff training so it was clearer what training people had received and future training could be planned. Monthly induction days had been started for all new staff so they received relevant training as soon as possible after starting to work at the home. A customer services manager had been appointed to oversee all aspects of the service delivery to people other than care, for example laundry, cleaning and the provision of social activities and events. The customer services manager aimed to build early relationships with people as they moved into the home so they had a point of contact and could identify someone immediately to raise concerns with or make suggestions or comments. What they could do better: Although there was a commitment to providing opportunities for recreation and social stimulation for people, one of the social life coordinators had left and one was off on sick leave so the remaining social life coordinator was limited in how much time she could spend on each unit. It was reported that one of the carers would be designated to help her to make sure that social activities and events were still offered to people. Additionally development of the key worker system should be considered to help staff work with people in identifying pastimes and social pursuits that meet their individual needs and abilities. As previously stated, at the time of the inspection the kitchen was being refurbished. There were also other issues relating to the environment that needed addressing. These included looking at the nurse call system on the Balmoral unit, as it can not be heard in all parts of the building, ensuring that radiators are guarded if indicated following risk assessment and reviewing the security of the Balmoral unit (arrangements for access) and the policy for wedging open fire doors. Quality assurance and monitoring processes were in place, which could be excellent if they were followed through in their entirety. Audits (checks) were carried out regularly Care Homes for Older People Page 9 of 32 but all fell down slightly, in that it was often not clear that where shortfalls were highlighted, the actions that were identified as being needed to address them were actually carried out. For the quality assurance systems to be really effective and useful in developing a continuous cycle of improvement this final step needs to be more robust. There was no record of recent fire drills for staff despite one drill in January 2009 identifying that some staff needed more training. Staff must participate in regular fire drills and have associated training to ensure they aware of the procedures to follow in the event of a fire. 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 10 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 11 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. People were fully assessed before they came to live at the home so staff could determine if their needs could be met. Evidence: We looked at the care provided to four people in detail, looking at the information obtained before they came into the home and how that was used to develop a plan of care for each person. Assessments had been undertaken for all of the people before they came into the home and the assessments were detailed and covered all the different aspects of their care needs. The information obtained had been used in each case to create individual care plans, to tell staff what help each person needed and what their abilities were. It was reported that a handover was given at the start of each shift, so staff got up to date information about peoples changing care needs and were told about what care Care Homes for Older People Page 12 of 32 Evidence: they needed to provide for new people being admitted to the home. Care Homes for Older People Page 13 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were involved with the development of their individual care plans so they received the care and support they needed in the way they preferred. Evidence: We looked in detail at the care provided to 4 people; 2 people lived in the Main Hall and 2 people lived on the Balmoral unit. Care plans were in place for each person, which were mainly detailed and provided good information about their individual preferences, personal care and health needs and daily routines. Risk assessments had generally been undertaken for each person in respect of moving and handling, pressure areas, nutrition, falls and the use of bed rails where applicable. One person did not have a nutritional risk assessment and had been weighed on admission to the home in July 2009, but not again since. Although there were no obvious concerns about her weight, good practice would be to ensure that each person was weighed at least monthly. Another person had lost 17.6kgs between 30/4/08 and Care Homes for Older People Page 14 of 32 Evidence: 19/7/09. Although their body mass index (BMI) was still within the norm, their care plan did not highlight that their weight had been decreasing, so it was not raised for staff as an issue that could potentially become a problem for the person. Care plans and risk assessments were usually reviewed monthly but not always and on the Balmoral unit there were a number of gaps in the daily records for each person. Detailed daily records are good practice as they help the manager check the care being provided and ensure staff are following the guidelines in the care plans. Daily records show what staff have done and provide the evidence on which to base the monthly review of care plans. Records showed that people had seen their GPs opticians, chiropodists and podiatrists. Other health care professionals such as the tissue viability nurse had been contacted by staff when needed and one person had been referred to the audiology department at the hospital when they said at their care plan review that they felt they needed a hearing aid. We saw that on the Balmoral unit the care files for each person had been checked (audited) to make sure that all the relevant documentation was accurate and up to date. A form at the front of each file identified shortfalls in the records and stated what needed to be done to rectify them. This was good but needs to be taken a step further, as the actions needed had not been carried out, even where it was stated that staff needed to address them straight away, so the shortfalls were still apparent. Care needs to be taken that staff follow as closely as possible the actions stated in the care plans. Two people were seen lying in poor positions whilst being fed enterally (by a tube directly into their stomach), although their care plans said they should always be sat up when the feed was being administered. Lying in a poor position presents a risk to the person that the feed could go into their lungs. Both the people living in the Main Hall had had reviews of their care plans, which they had been involved in. One person on Balmoral unit had not been at the home long enough for a review to be due and it had been identified that the other person was due a review and this was being arranged. A visitor to someone else living on the Balmoral unit told us he had been contacted to arrange a review of his relatives care. People told us they were happy with the care they received and that staff treated them with dignity and respect. Comments included, Staff are very good. Weve no complaints whatsoever, Theyre lovely and the younger ones are so joyful and staff are excellent- very good. One person told us they had come into the home because Care Homes for Older People Page 15 of 32 Evidence: the relative who had cared for them had died suddenly and they felt they would not have coped with their loss without the support of the staff. A relative said Staff are very tolerant and prepared to listen even though often there are other things waiting to be done. We looked at how medicines were managed for a small number of people. Systems were in place to minimise the risk of errors and promote the safety of people living at the home. Care Homes for Older People Page 16 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. Ongoing improvements to the kitchen facilities and ancillary staffing arrangements are benefiting people living at the home. Evidence: A weekly activities programme was distributed to everyone each week and was also displayed in prominent areas around the home. Since the last inspection one of the social life organisers had left and another was on sick leave so there was only one social life organiser who also had to work at The New Windsor home. However, it was reported that a carer would be helping her to make sure social activities and events were still offered to people. The activities programme showed that an entertainer (an accordion player) had visited the home the previous day. People told us they had enjoyed this. A Pat Dog was visiting on the following day and people told us they liked seeing animals in the home. Other activities for the week included games and bingo. Several people told us they particularly appreciated the chaplain who works at the home; both for the time she spent with them individually, providing pastoral care and for the communion services she held. Care Homes for Older People Page 17 of 32 Evidence: Of the people that we looked at in detail, some had information about their life histories, previous interests and hobbies etc included in their care files, whilst some did not. A record had been made most months of how people had spent their time and up until one of the social life organisers being on sick leave, it appeared that some time was spent with people on a one to one basis where possible, if they were unable to or did not want to join in with group activities. Some people said they preferred to spend time in their own rooms, reading or watching TV and several people told us they went out of the home with their relatives and friends. Consideration should be given to expanding and improving the key worker role to help staff work with people in identifying pastimes and social pursuits that meet their individual needs and abilities. Although a key worker system was in operation a carer we spoke to did not know which people she was key worker for and had no concept of the role. Work had started the previous week on refurbishing the kitchen on the Balmoral unit. At the last inspection inadequate kitchen facilities appeared to be a major factor in the general dissatisfaction expressed by several people about the provision of meals in the home. The manager reported in the AQAA that since the last inspection a person had been appointed to help specifically with serving meals and a new Head Chef and Second Chef had been employed. Already, with these changes comments seemed to be more positive about the quality of food provided and people told us they felt there had been some improvements. On the day of the inspection lunch on the Balmoral unit was served in 2 dining areas. Despite the building work going on, the disruption to people having their meals seemed minimal and the atmosphere in the larger dining room was relaxed and pleasant with music playing quietly. Tables were laid with cloths, flowers and condiments. The lunch time menu consisted of fruit juice or butternut squash and sweet potato soup, liver, bacon and onions, mashed potato and carrots, followed by bread and butter pudding and custard. People said they were enjoying the food and we tried some of the liver and it was delicious. Although there was no formal choice of meal written on the menu, 3 people said they did not like liver and were offered alternatives of omelette, sandwiches or cheese and biscuits. Two people chose the omelettes and after waiting a few minutes were served fresh, hot omelettes that looked very nice. The other person chose cheese and biscuits and was provided with a good selection of cheese and grapes. We were told that once the kitchen had been refurbished new menus would be implemented and there would be a choice at all meal times. Care Homes for Older People Page 18 of 32 Evidence: We did notice that a significant number of people were served breakfast quite late in the morning - between 10am and 10.30am. As lunch was served at 12.45pm this did not leave much time between meals. This was discussed with the manager and is discussed further in the staffing section of this report. A hot breakfast was provided each day or a choice of cereals, porridge and toast. At tea time in the Main Hall people were offered a choice of fish pie, potato scallops and peas or a selection of sandwiches. 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. Procedures were in place in the home so that people could express their concerns and be listened to, their rights were protected and they were safeguarded from abuse. Evidence: The complaints procedure is displayed in the reception areas of the home and is also provided in the homes service user guide. All the 10 people living at the home that returned surveys said they knew who to speak to if they were unhappy and were aware of the formal complaints procedure. People that we spoke to on the day of the inspection were able to name a member of staff they would speak to if they had a complaint and generally felt reasonably certain that any issues would be addressed. One visitor told us they had raised several minor issues and if they had phoned to speak to the manager he had always responded quickly and dealt with their requests. Since the last inspection the manager had started to hold weekly surgeries where people living at the home or their representatives could arrange to see him. This seemed to be working well and one visitor told us he had welcomed the opportunity to meet with the manager and voice his opinions as it made him feel he was involved in his relatives care and his feedback was valued. The manager had kept records of the discussions he had had and where appropriate what action he had taken as a result of the feedback he had received. However, where actions involved other staff it was not Care Homes for Older People Page 20 of 32 Evidence: always clear how this was taken forward and followed up to make sure the necessary changes were implemented. Since the last inspection a customer services manager has been appointed, to liaise closely with people living at the home and their families, building up relationships when they first move into the home and addressing any minor issues immediately. A record of complaints received by the manager was held together with the actions taken to investigate and respond to the complainant. In the AQAA it was reported that there had been 11 complaints - 1 was currently being dealt with and the other 10 were all responded to within the timescales stated on the complaints procedure. Where an investigation found that mistakes had been made an apology had been given and the complainant was told what steps were being taken to make sure standards did not fall below what was expected. Since the last inspection there have been 2 safeguarding investigations. One was initiated by the manager and related to the practices of an agency member of staff. The other followed a complaint made by a relative and an investigation found that whilst there was no evidence of willful neglect, poor documentation meant that there was no structured formal tool for proper assessment and evaluation of this persons health care needs. This meant the actual level of care provided could not be properly demonstrated. In response to the findings of the investigation Barchester developed an action plan to address the issues that were raised, which included further staff training and changes to the staffing team. During this inspection we were able to confirm that the staff training had taken place and was ongoing. Staff receive training in safeguarding adults as part of their induction and on an ongoing basis. 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. People live in a clean and comfortable home where ongoing refurbishment is being carried out. Evidence: We carried out a partial tour of the home. The home was clean, tidy and comfortable for people to enjoy relaxing in. In the AQAA the manager told us various improvements had been made to the environment since the last inspection, including the provision of a new servery in the Main Hall, the fitting of fire break glass bolts to all fire doors for security improvement, the refurbishment of some bedrooms and a lounge and the creation of a new staff office on Balmoral. Major work was being carried out at the time of our visit to upgrade the kitchen facilities. Many bedrooms were highly personalised with pictures, cards, flowers, soft toys and ornaments and were very homely. The hallways and communal areas were attractive with flower displays and pictures. Each lounge had a large flat screen TV and CD player. At the last inspection we did raise concerns about the security of Balmoral as we had been able to enter the building unseen for at least 10 minutes. At this inspection we Care Homes for Older People Page 22 of 32 Evidence: were also able to enter Balmoral through a fire escape, and although because of the time of day (early morning and breakfast time) staff were at that end of the building, access should still be reviewed because it is still possible that someone could enter the home and go into peoples rooms unchallenged. One radiator in the hallway in Balmoral was very hot and was unguarded presenting a potential hazard to people. Peoples bedrooms doors were wedged open with a variety of items such as plastic and metal waste buckets, a case, wheelchairs, armchairs and shoes. We discussed this with the manager and he had just received a letter from Barchesters property director saying that Barchester were aware this was an issue in many of the homes in the group and they were planning to address this with the installation of self closing doors where appropriate. On the Balmoral unit the nurse call system was not audible in all parts of the building and this was highlighted at the last inspection. It was reported that quotes had been obtained for a new nurse call system and this would be looked at again once the work on the kitchen was completed. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in staffing arrangements and training were helping to ensure that people were in general cared for and supported safely. Evidence: At the last inspection we said that although on paper staffing levels appeared to be sufficient, people had told us that they did not always feel there were enough staff on duty. The length of the hallway in Balmoral, the deficiencies in the nurse call system and the 3 floors in the Main Hall all present challenges for staff and need to be taken into account when deciding how many staff are needed to realistically meet peoples care needs especially at the busiest times of day ie meal times and when people are getting up and going to bed. We recommended that staff rotas were written to take into account the skill mix of staff and to ensure that less experienced staff were appropriately supported and supervised until they had received sufficient training to enable them to carry out their jobs competently and effectively. Since the last inspection recruitment has been given a priority and it was reported that two nurses would be starting to work on the Balmoral unit imminently. Although some people still told us that they sometimes had to wait for help when they needed it and one visitor commented that staffing was pretty much the minimum, several people did feel staffing had improved slightly. Care Homes for Older People Page 24 of 32 Evidence: We did have concerns that a lot of people on the Balmoral unit were only served breakfast mid morning. In addition staff were unable to follow peoples care plans because they were too busy, when they said that the person should be checked every half hour or every hour when they were in bed because they were unable to use the nurse call system to summon help. In the Main Hall many people were in bed in the early afternoon and it was not immediately clear if this was entirely due to their choice, because their medical condition necessitated it or because staffing levels were such that people were safer in bed and it was easier to manage their care given the number of staff on duty. These issues were discussed with the manager and we were told that once the kitchen refurbishment was completed, changes to staff roles and extra ancillary help would free up more time for carers and nurses and the manager was confident that the improvements already made to staffing would be built on and sustained. It was encouraging to see that the Home Trainer was working on the morning of our inspection, with a carer on a one to one basis, giving practical instruction about how care was to be delivered. The Home Trainer also told us that an induction day was now held monthly so all new staff were able to attend the training as soon as possible after starting to work at the home. On the Balmoral unit a new unit manager had been appointed who was very enthusiastic and experienced and the unit seemed to be more organised and effective. Since the last inspection an individual training file had been provided for all staff and the Home Trainer said she was going to develop a training matrix to highlight what training was due for each staff member. One new member of staff confirmed she had received induction training that had included fire safety, moving and handling, safeguarding adults etc. Records showed that staff had been provided with training in a range of topics such as enteral feeding, first aid, blood glucose monitoring, wound care and challenging behaviour. Further training was planned in baseline urinary assessment, recognising infection in wound care and appraisal. Two staff personnel files were examined. Both contained the documents and evidence necessary to ensure that people recruited were suitable to work in a care home. In the AQAA it was reported that 70 of care staff had successfully completed NVQ training. This was a significant increase from the last inspection. 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. Improvements in the management systems ensure the efficient running of the unit and the ongoing improvement of the service. Evidence: At the last inspection we had concerns that people did not feel their views were being listened to and that the management of the home were perceived a being distant and unapproachable. Since then the manager has started to hold weekly surgeries which were advertised around the home, inviting anyone that wished to speak to him to meet and discuss any concerns or voice their opinions. In addition, as stated previously, a customer services manager had been appointed whose remit was to oversee all services other than care, such as the laundry and cleaning services and the provision of social activities. The customer services manager was also responsible for showing people around the home if they were considering going to live there and was therefore able to introduce herself at a very early stage and become the first point of contact for people if they had suggestions, comments or Care Homes for Older People Page 26 of 32 Evidence: concerns. The manager said that once the kitchen refurbishment had been completed resident/relative meetings would be introduced on each unit. These had not taken place for a while, as the last one was held for the whole home and the manager felt it was not especially helpful due to the large number of people that attended and the resulting inability to address individual comments. Barchester had systems in place to review the quality of the service delivered to people. Monthly internal audits (checks) were made across a range of areas and staff practices, such as provision of activities, infection control, record keeping, health and safety, nutrition and the dining experience and the management of medicines. All the quality monitoring mechanisms in place fell down slightly, in that it was often not clear that where shortfalls were highlighted, the actions that were identified as being needed to address them were actually carried out. From speaking to people we could tell that some issues they had raised had been dealt with but often the records did not show this. For the quality assurance systems to be really effective and useful in developing a continuous cycle of improvement this final step needs to be more robust. Small amounts of money were held in the home for some people. It was reported that receipts were kept for all transactions but we did not examine these in detail at this inspection. Fire logs were kept for each of the 3 units, which showed that regular checks were made of the buildings and fire fighting equipment. Records were also kept of staff fire training and drills but did not always clearly show which unit staff were working on. It appeared that the last fire drills on the Balmoral unit and the Main Hall had been on 28/1/09, when it was identified that the staff on the Balmoral unit needed more training and practice. The fire risk assessment completed in April 2009 also said that there were not sufficient staff trained in the use of fire fighting equipment and it was not clear if a training programme had been implemented specifically to address this. The manager returned the AQAA to us on time and it contained detailed information about the improvements that had been made since the last inspection and plans for the future. We requested that surveys be distributed to a number of people living at the home but 60 of them were completed with the help of staff. When people are helped to complete the surveys by staff we think they may feel less able to be frank in their views. The surveys completed by staff contained very few comments whilst the surveys completed by people living at the home or their relatives were much more informative and gave both positive and less positive feedback. Care Homes for Older People Page 27 of 32 Evidence: It was reported that two members of staff had undertaken training in the mental Capacity Act Deprivation of Liberty Safeguards (MCA DOLS) and were planning to roll out training to the rest of the staff team. No one living at the home was subject to an application being made under this legislation at the time of our inspection. Care Homes for Older People Page 28 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 29 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 38 23 Staff must receive sufficient training in fire safety and use of fire fighting equipment including participating in fire drills. This will ensure that staff understand the procedures that need to be followed to maintain the safety of themselves and people living in the home in the event of a fire. 30/11/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Daily records of the care given to people should be written. This will show what care each person has needed and can be used when reviewing care plans. People should be weighed monthly or more frequently if they are identified at high risk and care plans should highlight weight loss and the actions taken by staff to address this if appropriate. 2 8 Care Homes for Older People Page 30 of 32 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 3 4 5 19 22 25 The security of the home should be reviewed to ensure that staff are aware of all visitors entering the buildings. The nurse call system should be upgraded to ensure that on each unit it is audible to staff in all parts of that unit. Risk assessments should be carried out where radiators are unguarded and should be fitted with guards where appropriate. The manager should develop the quality monitoring system one stage further so that it provides evidence of how feedback is used and acted on to improve the service. This will make it more robust and progress will be more measurable. 6 33 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. 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. 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