Inspection on 28/09/09 for Melrose House

This inspection was carried out on 28th September 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Melrose House 10/06/10

Melrose House 15/10/08

Melrose House 05/11/07

Melrose House 23/04/07

Melrose House 29/08/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Melrose House 95 Alexander Road Southend-on-Sea Essex SS1 1HD     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: Vicky Dutton     Date: 2 8 0 9 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 34 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 34 Information about the care home Name of care home: Address: Melrose House 95 Alexander Road Southend-on-Sea Essex SS1 1HD 01702340682 01702436551 melrosehouse@btclick.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Masood Rashid care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following categories of service: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 34 Date of last inspection Brief description of the care home Melrose House is a detached property which is registered to provide care and accommodation to up to 34 older people. The home is also registered to provide care for people who have dementia. Eight beds at the home are allocated for step down. This is a short term care arrangement with the local Health Trust. Bedrooms are situated on the ground, first and second floors. Some bedrooms have an en suite facility. Bathroom and toilet facilities are provided throughout the building. A passenger lift provides access to all areas. On the ground floor there are three pleasant communal lounges and a dining room. Melrose House has a pleasant garden Care Homes for Older People Page 4 of 34 Over 65 0 34 34 0 1 5 1 0 2 0 0 8 Brief description of the care home and patio area at the rear of the house. The home is situated in a residential area within a conservation area. It is within a short walking distance of Southend shopping centre and seafront. The home is also close to mainline railway stations and numerous bus routes. There is limited parking at the front of the property. On street parking may be available depending on the day/time. The current rate of fees is between £520.00 and £550.00 Additional charges are made for hairdressing, chiropody, clothing, papers, magazines and transport. Information about the home is made available to people in the Statement of Purpose and Service Users Guide. Care Homes for Older People Page 5 of 34 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: This was an unannounced key site visit. At this visit we (CQC), considered how well the home meets the needs of the people living there, how staff and management work to provide good outcomes for people, and how people are helped to have a lifestyle that is acceptable to them. We spent nine hours at Melrose House. We looked around the premises to see if it was pleasant and safe for people. We viewed some care records, staff records, medication records and other documentation to see how well these aspects of care and running the home are managed. Time was spent talking to, observing and interacting with people living at the home, and talking to management and staff. We also spoke to one visitor and a visiting professional during the site visit. We spent some time in one area of the home observing the experience of a group of people identified on their care plans as having dementia. This is because people with dementia are not always able to tell us about their experiences and we wanted to find out about their experience of Care Homes for Older People Page 6 of 34 care. The homes Annual Quality Assurance Assessment (AQAA) was sent in to us when we asked for it. The AQAA is a self assessment tool that providers are required by Law to complete. The AQAA should tell us how management feel they are performing against the National Minimum Standards, how they can evidence this, and how they have addressed any previous requirements and recommendations. The AQAA for Melrose House was poorly completed and did not fully address the above items. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives, involved professionals and staff. We received responses from ten residents, five relatives, two visiting professionals and three staff. The views expressed at the site visit and in survey responses have been incorporated into this report where appropriate. We were assisted at the site visit by the manager and other members of the staff team. Feedback on findings was provided throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? Since the previous inspection an activities room has been developed for the benefit of residents. This provides a pleasant space where people can be creative, play games or just socialise. Care planning at the home has improved in some respects, and care plans now provide a clearer picture of residents needs for staff to follow. Records have been developed to ensure that peoples diet is monitored. Refurbishment at the home is progressing. Further areas have been redecorated and three more rooms now have an en-suite facility. A ground floor bathroom has been upgraded. Staff training has been ongoing. In particular staff have now undertaken or are completing training in dementia care which should improve their understanding and practice. A training matrix is now available to help management track when training updates are due and where there might be gaps in staff knowledge and training. When staff start work at the home they are now undertaking a proper induction programme. This should ensure that they develop good skills from the beginning of their employment. The registered provider is now fulfilling their responsibility to formally visit and assess Care Homes for Older People Page 8 of 34 the home on a monthly basis. 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 34 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 34 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 can feel confident that staff will, through assessments, try to ensure that the home is suitable to meet their needs. Evidence: The home had an up to date Statement of Purpose and Service Users Guide in place. The manager said that a Copy of the Service Users Guide is now given to people when they enquire about the service to give them information about the home. On surveys however five people said that they had received enough information about the home, and five that they did not. The home may therefore need to review how they give information to people to help them to make decisions about their ongoing care. We saw that a copy of the Service Users Guide was available to people in their rooms once they move into the home. As pointed out at the previous inspection, the current service users guide does not include details of fees and additional charges as is now required. Care Homes for Older People Page 11 of 34 Evidence: To ensure that Peoples needs can be met by staff, an assessment of their needs should be undertaken before they move in. We looked at the file of a person who had recently moved in to see if this was happening. We saw that satisfactory assessments of the persons needs had been undertaken, and that additional information was available from the hospital involved with their care. The step down (see below) coordinator said that the manager always assessed peoples needs before confirming that they were suitable for a stay at the home. The manager said that they do on occasion say no to a proposed admission if they feel that the home would not be able to meet their needs. Intermediate care is not provided at Melrose House, but there is provision for up to eight people to use the home on a step down basis. This is where people who have been in hospital move into the home for a short period of time to complete their recovery, wait for care packages or adaptations to their own homes, or have some rehabilitation in a non-clinical setting. People stay at the home for a few weeks before returning home, or making the decision to move permanently into residential care. People continue to receive support from staff such as physiotherapists, occupational therapists and nurses to aid their recovery during this period. A brochure is available to people explaining the step down process. Again the home need to ensure that people understand what the process is. One person spoken with who was placed at the home under the step down arrangement did not seem to know the term. The person said, No one seems to know anything about me. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot expect to receive consistent care based on their identified needs and preferences. Evidence: During the day people told us that they were happy with the care received at Melrose House. People were generally well groomed and appropriately dressed. Six out of the ten people who had sent back surveys had been assisted in this by the deputy manager. They all said that they always received the care and support they needed. The other four said that they usually received the care and support needed. Relatives said: Some carers support the residents very well, others are not as skilled, and, I have no complaints about the service the home provides. My [relative] is well looked after. During the inspection the step down co-ordinator and other step down staff visited the home. They felt that the standard of care in the home was fine and that staff were helpful. To see how well care is planned for and arranged so that staff are aware of peoples needs, and can meet them in an individual way, we looked at a number of care files. Care Homes for Older People Page 13 of 34 Evidence: The previous inspection raised significant issues relating to care planning, delivery of care, management of medication and privacy and dignity issues. Requirements were made relating to these issues. The Annual Quality Assurance Assessment (AQAA) completed by the manager this year did not give us any indication as to whether these issues had been addressed. The AQAA was poorly completed and did not give us much useful information. For example for this section under, How we have improved over the last 12 months it just said, We have put en-suites in three bedrooms for the service users. Changed the assessment form. At the site visit the manager said that they had worked on care plans and that they were much improved. When we looked at care files we saw that they had been improved, provided clearer information about peoples needs and attempted to achieve a person centred approach in some cases. Care plans would enable staff to be aware of some of peoples needs and deliver appropriate care. There remain however a number of issues and shortfalls that may prevent people from receiving good, safe, person centred and holistic care on a consistent basis. Throughout the day we observed that things identified in peoples care plans were not carried out in practice. For example for one person it was identified that they liked to sit at a dining table where they could see out into the garden. They were sat with their back to the window. Two people were identified as, Must sit on a spenco cushion at all times. This did not happen. Where people had short term care needs such as having a sore, using creams or ointments or being on anti-biotics for an illness, care plans are not put in place to make staff aware of these issues and a change in care needs. Some care plans still lacked a good level of detail with comments such as, needs full assistance with teeth, hair, shaving and bathing. Although risk assessments are referred to in the index of peoples care files, none could be found. For one person with dementia staff were observed to attempt to move them with a stand aid hoist, an attempt that was soon abandoned. The persons care plan made no mention of this and there were no moving and handling risk assessments in place. This had the potential to place both the resident and staff at risk. Daily records are maintained but these do not give a feel for the person and how they have spent their day, has been fine, ate well and bowels open were the main themes. The manager agreed that this was not adequate. Records showed that people access appropriate health care to meet their needs. On surveys most people said that they always received that medical care that they needed. One person however said, By the time I got a doctor I was feeling better. Records of health professionals visits are well maintained. However as identified above issues arising from visits such as the use of creams are not then carried forward onto care plans. Care plans incorporate assessments for nutrition. Currently the home only have stand on scales available. Therefore frailer residents who are unable to stand will not be able to have their weight monitored to alert staff to any changes. Since the Care Homes for Older People Page 14 of 34 Evidence: previous inspection nutrition records have been developed to ensure that peoples diet is monitored. Although they were in place at the previous visit, at this inspection assessments to identify people at increased risk of falls were not available on files viewed. In addition to this a number of people were using zimmer frames where the ferrules were worn through to the metal. This could increase the risk of falls. As the home offers a step down service it could be expected that the home would have a strong ethos of encouraging people to be independent and autonomous so that they retain the skills needed for returning home. The manager felt that the home did do well in this area. However observations did not support this. Staff routinely moved people about in wheelchairs. One person was observed to have a conversation with the step down co-ordinator who was asking how they were getting on, and if they were still walking with their zimmer frame. Their care plan for mobility said, Walks with a zimmer frame but needs reminding to use it. Later a member of staff came in with a wheelchair. They did not offer the person a choice, but just took them to the toilet and then on to the dining room in the wheelchair. Medication at the home is generally well managed and no errors in records or the system were identified. A resident said, They always give me my medication on time. A relative said, Medicines are given regularly and appear to be carefully monitored. The last inspection raised concerns about the management of creams and topical applications. Although this was much better this time, we still found pots of unlabeled creams in some rooms. An unlabeled pot of aqueous cream on top of the radiator cover in one room had an expiry date of 06/07. If creams are not used within dates they may no longer be clinically effective or may be unsafe for use. Since the previous inspection protocols have been devised for people who have medication to be taken when needed, (PRN.) These take the form of care plans and are kept in care files, as opposed to with medication records where they would be to hand to aid administration. As previously advised protocols should make it clear what the tablets or medicines are prescribed for. Other best practice issues highlighted at the previous inspection such as the need to ensure that handwritten entries on MAR sheets are signed by two people to confirm that details recorded are correct, and to date boxed/bottled medication when commenced to provide a good audit trail are still not being consistently maintained. The home were however able to show that good information to guide staff practice is now available. Staff administering medication have received training to do this. We saw that staff are completing/have just completed a good quality twelve week distance learning course in dementia care. However observations indicated that this training has not yet translated into improved outcomes for residents. On a survey one person felt that what the home could do better was; Dont talk down to people, treat Care Homes for Older People Page 15 of 34 Evidence: them like adults, make step down feel the same as residents, not be told youre an outsider, and being left to last for everything. Some good practice was observed such as a member of staff noticing (albeit after some considerable time,) that a resident had food and dribble down them and asking if they could wipe it up. A visiting professional felt that staff; Focus on clients at all times, are courteous, respectful and preserve dignity at all times. However this was not borne out by our observations on the day of the site visit. Staff observed assisting one resident said, Are you going to be a good boy and get in there today. Staff were not patient in their approach and were getting frustrated when the resident (with dementia) did not do as they were asked. They did not allow the person time to comply before going off again. One resident with nothing on their legs was sat in a chair with their legs raised. They were not offered a cover for their bare legs. Staff talked over residents with comments such as, Wish I hadnt come back, Need to get X out of the way, Well have to leave [them.] One persons care plan said, X sometimes needs some assistance with eating. Their meal was put in front of them, with no offer of help/cutting up etc. They were then putting large pieces of meat into their mouth spilling gravy and meat down their chin and so on. Staff do not always appear to be communicating well with residents. Residents were given mixed messages which might be confusing for people with dementia. For example one member of staff asked if anyone wanted more tea. Some indicated that they would, but no tea ever came, and then residents were taken in for lunch. One person was seen in a wheelchair having been left by a wall opposite the lift. When asked if they were waiting to go downstairs they said, I think so. On a survey a relative said, Greater consistency needed in giving instructions to residents [relative] is sometimes upset by being told different things by different people. These issues do not demonstrate a good understanding of respecting people and supporting their dignity. Care Homes for Older People Page 16 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will have some opportunities for occupation and will always be able to welcome their visitors. People may find that arrangements for meals and refreshments do not met their needs and preferences. Evidence: Since the previous inspection an activities space has been created in a former office. This was a nice bright and pleasant room. Plenty of equipment such as games and craft equipment was available. Evidence of residents art work was up on the walls. On surveys most people felt that there were activities available to them. At the site visit residents were left to their own devices during the morning, and received only task orientated staff input. A quiz and manicures took place in the afternoon. In the lounges televisions were on all the time, often at a level too low to be heard. Even in one lounge when a quiz took place in the afternoon, the television was still on with the sound turned down. Residents spoken with said that they were often bored, and that there, Was nothing to do. One person said that they would like to go out to the shops or the park. The manager said that people did go out, but could only find one example of this. Relatives said: Little to entertain or occupy residents - those not visited or taken out by relatives need more input from staff, I was pleased to see that they now have an entertainment room as when X first moved in there they used Care Homes for Older People Page 17 of 34 Evidence: to get bored a lot as they were always a very active person, and, Maybe they could take the clients out to the seafront more often. When we spent time observing in a lounge the television was on but people were not watching or engaging with it. There was nothing else in the room to provide stimulation or occupation. People just sat and dozed, gazed blankly or amused themselves by, for example fiddling with a beaker. Outside entertainers visit the home on a periodic basis and residents said that they enjoyed this. Peoples care files viewed all had a social activities care plan in place. As at the previous inspection, for people with dementia there was no clear process in place for assessing their social or occupational needs. Instead care plans outlined things such as likes to sit in lounge 3, (the person was sitting in lounge 2), when their visitors came, and generalised likes to watch TV, or will join in with activities. Activities records are maintained. Activities recorded included quizzes, exercises, chatting, colouring, sing along and board games. The manager recognises that activities is an area where improvements are needed. One member of staff has recently undertaken a training course in activities, and the manager wants more staff to undertake this. They also want to, Use the dementia training more in social activities. Currently there is no provision for people to fulfill any spiritual needs. The manager said that no one has expressed any need for this at the moment. Visiting at the home is very open and is always encouraged. People felt that the home communicated well with them. One person said that the home was, Accommodating for family phone calls. Another that, Has open house for visiting - Good The homes Service Users Guide contained useful information for people about advocacy services and other organisations that may provide independent support and advice. It also explained that people are able to bring in their own possessions when they move into the home. Some rooms viewed were homely and people had clearly brought some of their own belongings and personal memorabilia in with them. The manager is aware of recent legislation relating to mental capacity and deprivation of liberties. Information about these topics was readily available for people. The home operates on a basic four week menu system that is said to be changed according to peoples choices and comments. An A4 size weeks menu plan was posted on a notice board in the dining room. Menus viewed showed that a good range of foods are provided, with plenty of fresh vegetables. People have to choose their main lunchtime meal the day before. The manager said that if people change their minds this is accommodated. People were generally positive about the food provided. Comments made were: Nice dining room, The food is very good, My meals are always nice and on time, Food is generally good and individual preferences met, Care Homes for Older People Page 18 of 34 Evidence: and, They could offer more variety at mealtimes, e.g different sandwich fillings for those residents still interested in food. Ensure residents are offered a chance of further portions if they wish. On the day of inspection arrangements for meals and refreshments were not particularly good. At 10.45 there were still 10 people sitting in the dining room having either had their breakfast and still waiting to be assisted to the lounges, or, still waiting for their breakfast. One person was getting impatient about this and was waiting for their toast. Another person with dementia was amusing themselves by mixing sugar and sauce together in a cup. When we were spending time observing in a lounge, a member of staff arrived with drinks at 11.30. People were not given a choice, but just had a cup of tea put down by them or given to them. Some people (with dementia) had no table to hand so had to balance a cup and saucer on the chair arm. The member of staff then brought in biscuits. Again no choice was offered, biscuits were just handed out. There was no staff supervision in the lounge. One person had been given their tea in a feeder cup. They promptly took the lid off, spilled the tea down them and tipped some over the floor. Staff were not aware that they had not had a drink, and later did not notice that they had wet trousers. As previously noted the member of staff later offered more drinks to some residents, but never brought any. One resident was brought down at nearly 12.00, staff said that they were going to get their breakfast, but never did. One residents routine was to remain in the lounge for their meal. The meal and pudding were brought in hand held by a member of staff, not covered or nicely presented on a tray. At lunch time in the dining room people were not offered appropriate support or supervision. (See earlier comments). At tea time while we were in the dining room there was no care staff support. People were left with their meals (cold meat and pickles) in front of them. One person started eating with their hands, another person was interfering with the meal of the person next to them, and covering their own with a cloth. With some people not having their breakfast until very late, lunch at 13.00 and tea at 16.30, meals are quite closely spaced, this could mean that people do not eat as well as they might do with longer between meals. Care Homes for Older People Page 19 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by staff who have the knowledge needed to ensure their safe care. Evidence: Melrose House has a clear complaints procedure in place that is available to people. In discussion, and on surveys, people told us that they knew who to speak to if they were not happy, and knew how to make a complaint. We viewed the homes complaints records, and saw that no concerns had been recorded since the previous inspection. One safeguarding referral against the home had been made since the previous inspection. This related to care and staff attitude. The allegations were looked into by social services and found to be not substantiated. Staff have received recent training in safeguarding people through a six week distance learning course. We saw that the most up to date local authority safeguarding procedures were available. A staff training pack was also available. Following the last inspection the home sent us a copy of their own safeguarding policy and procedure. Staff spoken with understood what safeguarding meant. Safeguarding information and relevant contact details of local safeguarding teams are readily available for staff. This should mean that people are cared for safely by staff who understand their responsibility to report any concerns. Although the manager felt that this was not currently a major issue, some people Care Homes for Older People Page 20 of 34 Evidence: living at the home, due to their dementia, can be challenging in their behaviours. Records showed that if problems with behaviour develop, relevant professionals are involved to try and address the situation. Following the last inspection the manager said, I am looking at finding more outside training on behavioural needs - we will also be doing in house training and ensuring needs are put in care plans. We saw that care plans were in place to assist staff practice. Although no specific training in challenging behaviour has taken place the manager felt that the recent dementia training had covered this area to some degree. Care Homes for Older People Page 21 of 34 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 comfortable home where they are happy with the level of cleanliness. Evidence: Since the previous inspection the provider has continued to gradually redecorate and improve the premises. Three more rooms now have an en-suite facility, and an upstairs flat has been converted into three further en-suite rooms. These rooms have been registered by the Commission. One person who had been at the home for about a week said that they were very happy with everything and liked their room. Some comments about the environment were: Redecoration has improved the home environment, but cracked door and neglected frontage are a depressing sight for visitors as well as residents, Heating levels sometimes seem low and residents complain of feeling cold, My [relatives] room has been extensively re-decorated, and, They could make the garden a bit more inviting. A member of staff said, Things are getting better every year as we go. Remember our home is under refurbishment, painted, new carpets have been put on. Most of the rooms have toilets inside which will be easy for us carers. Other things, mentioned as planned last year such as extending the dining room, new carpets in communal areas have yet to be achieved. When we went around the building we saw that areas such as store cupboards and bathrooms used for storage were left open. As well as posing a potential hazard through some of the things stored there, these areas looked unsightly and detracted from a homely environment. Care Homes for Older People Page 22 of 34 Evidence: The home has three lounges for people to choose from, and these were homely. A visiting professional to the home said that they liked using Melrose House as it was, homely and comfortable for people. Communal corridor areas have been made more interesting through the use of pictures and mirrors. The home has a garden for people to enjoy. The manager plans to develop this area further. At the moment two bathroom areas are being used for storage. A further bathroom on the second floor is not assisted, and was noted to be kept locked. This leaves one shower room and one assisted bathroom available for use. Both of these are on the ground floor. The manager said that the other bathrooms will be updated in due course. People should however have good facilities close to their rooms. People living on the second floor of the home should not be having to come down to the ground floor for a bath or shower. There appeared to be sufficient equipment such as hoists to meet peoples needs. As mentioned earlier staff make extensive use of communal wheelchairs. It was noted that these were dirty and not well presented. The manager said that they were cleaned regularly by the handy person who had left the week before. However it was doubtful if the state of the wheelchairs represented not being cleaned for only one week. On surveys most people felt that the home was always fresh and clean. Some comments made were: They do well at keeping the home clean, beds are always changed, Keeps everywhere well cleaned, Usually keep it clean, and, Beds are changed regularly and most of the home is clean (occasional exceptions.) On the day of the site visit the home seemed reasonably clean and only one area of poor odour control was discussed with the manager, who felt that this was due to a residents specific needs. Although there was information available to staff regarding cleaning expectations, there were no deep cleaning schedules in place to ensure a regular and cyclical approach to ensuring that high standards are maintained in all areas. Two members of domestic staff spoken with confirmed that they had undertaken appropriate training for their role. A training matrix however suggests that a number of staff have yet to undertake infection control training. Another barrier to achieving good infection control was that the two communal toilets on the ground floor most commonly used by people did not have adequate hand washing facilities. One had no soap or paper towels, the other did not have a proper hand washing sink. Only a hairdressing sink with a shower hose was available, and again no soap or towels. The homes laundry area provides sufficient equipment to meet the needs of the home. The area has been redecorated and cleaned since the previous inspection. The Care Homes for Older People Page 23 of 34 Evidence: area is now kept locked from the corridor side to protect residents from entering this potentially hazardous area. Care Homes for Older People Page 24 of 34 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. People who live at Melrose House may find that the home does not provide sufficient staff to support their needs. Evidence: We received generally positive feedback about staff at the home. People said: Staff always seem very caring even in difficult circumstances, I call in unannounced and at different times and have always found the staff helpful and caring, There is always someone to help me when I need help and staff are always happy, and, There is always a member of staff around if my [relative] requires anything. The improvement plan sent in following the last inspection said that for a trial period four carers were going to cover the morning shift, three the afternoon shift with an extra member of staff from 15.30 to 19.30 making four at that time. This was to be achieved by reducing night staffing down from three to two staff. When we looked at a months rotas we saw that morning levels during the week are generally maintained at four staff. However at weekends this can sometimes dip to three. The managers hours are often supernumerary. The extra member of staff on duty from 15.00 to 9.30 is in fact a member of the domestic team so in effect care staffing levels in the afternoon/evening are three. The home is over three floors and three new beds have been registered. There appears to have been no corresponding review of day and night staffing levels to ensure that they are adequate to meet peoples needs. The previous inspection advised that staffing levels be reviewed using a tool to assess Care Homes for Older People Page 25 of 34 Evidence: peoples dependency levels and ensure that sufficient staff are provided. This has not happened. People told us: Staffing levels sometimes appear low. Carers do not appear to have any time to spend chatting to the residents, Care could be more proactive. I do not think the residents are always closely monitored, though help is given when sought, and Sometimes I think we need more staff, as there is such a lot for the girls to do when we need so much assistance. There needs to be enough staff to ensure a tight check on what dementia residents are up to in relation to nondementia residents. Our observations on the day of the inspection confirmed these comments. On the day of the site visit the correct number of staff were on duty and the manager was supernumerary. Staffing levels did not appear adequate. Residents were left to their own devices for long periods of time with no staff contact. As highlighted in this report people were not properly supervised and supported. People were got up very late. Staff were task orientated in their approach. A resident said to us, They are well behind this morning, I think they said they are short staffed or something, nothing unusual there then. The manager said that it had been an exceptionally busy morning. However staffing should be sufficient to cope with the ups and downs of residential life without it potentially effecting the care and wellbeing of residents. A positive thing about staffing at Melrose House is that staffing at the home is fairly stable with a low turnover. Agency staff are not used. This provides stability and consistency for people. Management have done well in ensuring that staff access National Vocational Qualification (NVQ) training. This will enhance staffs skills in working with people. Out of twenty four senior/care staff only three do not yet have an NVQ qualification and one is currently working towards this. This shows a commitment to providing well trained staff. To see how well people are protected by the homes recruitment procedures we looked at the files of two recently recruited staff. These showed that good procedures are maintained and checks such as references, proof of identification, POVA first and Criminal Records Bureau (CRB) checks carried out. Relatives in general felt that staff at the home had the right skills for the job, although two comments were: There is considerable variation, and Not all care workers. On surveys staff said that their induction had covered everything they needed. On staff files we saw that good basic induction programmes were in place, which had been well completed and signed off. Since the previous inspection a programme based on a Skills For Care Induction programme has been introduced and is being worked through by new staff. A training martix has been developed. This showed that staff training is ongoing. In particular staff have now had good training in dementia care and Care Homes for Older People Page 26 of 34 Evidence: safeguarding vulnerable adults. The manager encourages staff to go on training and is always on the look out for further opportunities. On three staff surveys received people said that they felt supported. Records viewed showed that staff receive one to one supervision on a fairly regular basis. Care Homes for Older People Page 27 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot expect that the home will always be effectively managed in order to meet their care and safety needs. Evidence: The manager at Melrose House has been in post for over two years. They are registered with CSCI, and have appropriate qualifications and experience. Staff, relatives and people living in the home spoke well of the manager. The manager has a hands on approach and demonstrated a good knowledge of individual peoples needs. Whatever we needed to complete the inspection process was readily available. The provider is a frequent visitor to the home and a good relationship exists between them and the manager. At the previous inspection a number of requirements were made. Although it is clear that progress has been made, some requirements have not yet been met. The home have not yet achieved an effective, consistent and person centred approach in meeting peoples care and other needs. Since the previous inspection some surveys have been distributed to people and used Care Homes for Older People Page 28 of 34 Evidence: to gauge their satisfaction with the service. Each person who attends the home as a step down client is asked for their views on their stay in the home. Survey responses sampled were all positive. The home had also received a number of positive thank you cards and letters. We saw that people can express their views at residents meetings and one to one chats. Regular staff meetings are held for different designations of staff, so that practice and other issues can be discussed. The provider is a frequent visitor to the home and the manager said that they know all the residents and families well. They are now also undertaking formal monthly visits to review the service and talk to people about the service. This monthly visit is required to be undertaken and recorded by Regulation. The manager had completed the AQAA this year. Last year we pointed out that the AQAA was not well completed. We reminded the manager that the completion of the AQAA is a legal requirement, and that is an important document in our assessment of the service. This year it was again poorly completed and did not give us a good picture of how the home was operating. The AQAA did not address what actions and improvements had been made in meeting requirements made at the previous inspection. The manager felt that they had been hampered in completing the AQAA through doing it directly onto the computer in an electronic format. The manager confirmed that no monies or personal properties are held by the home for safekeeping. We did notice however that in an unlocked bathroom an ex residents personal possessions had been placed there for storage. People should expect that any personal items will be held securely. No major health and safety issues were noted on the day of the site visit. However some potentially hazardous things highlighted at this inspection such as keep locked cupboard doors being open and poorly maintained equipment such as zimmer frames were raised at the previous inspection. A recent inspection of the kitchen had found only minor issues to address. A fire service visit had found procedures to be satisfactory. Records showed that regular fire drills are carried out, and that a fire risk assessment was in place to protect people. Records viewed showed that staff are generally trained and kept up to date in core areas such as health and safety and fire. However moving and handling training for some people is overdue. The manager explained that this was about to be addressed. When training is undertaken the manager needs to ensure that it incorporates the appropriate use of aids. The attempted use of a stand aid with one resident has already been mentioned. On another occasion this piece of equipment was used for another resident but it could not be maneuvered in the space available so the person was put back in a wheelchair then physically manhandled over to their easy chair. This Care Homes for Older People Page 29 of 34 Evidence: using/not using equipment could be distressing and unsafe for residents and staff. Care Homes for Older People Page 30 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 Medication must be properly 02/11/2009 managed and accounted for. This refers to the management of creams and topical applications. People must be protected by clear policies and procedures in place. They should feel confident that creams and applications are used properly and in line with their assessed needs. 2 27 18 Staffing levels must be 28/11/2008 reviewed, with details of how the review was carried out and the outcome of the review to be sent to CSCI People must feel confident that sufficient staff are provided to meet all of their assessed needs at all times. Care Homes for Older People Page 31 of 34 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 Care plans must continue to 30/10/2009 be developed so that they encompass all of peoples care needs and clearly assess and address any risks associated with peoples care. Plans devised must be carried out in practice. So that people receive comprehensive, person centered and safe care. 2 38 13 Staff should be well trained in moving and handling and the appropriate use of equipment, with their practice monitored. So that practice in the home is safe for residents and staff. 30/10/2009 Care Homes for Older People Page 32 of 34 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 2 8 12 consideration should be given to providing sit on scales so that peoples weight can be properly monitored. People with dementia should have their social/activity needs properly assessed, and have appropriate opportunities offered to them for occupation in line with their individual assessed needs. Arrangements for meals and refreshments should be reviewed to ensure that they meet peoples needs and expectations. People should receive the support they need to maintain a good diet. To protect both residents and staff. proper hand washing facilities should be available in all toilet areas to promote good infection control. 3 15 4 26 Care Homes for Older People Page 33 of 34 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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