Inspection on 25/03/10 for Miranda House Nursing Home

This inspection was carried out on 25th March 2010.

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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Miranda House Nursing Home 29/07/10

Miranda House Nursing Home 06/04/09

Miranda House Nursing Home 06/10/08

Miranda House Nursing Home 24/09/07

Miranda House Nursing Home 15/09/06

Miranda House Nursing Home 24/02/06

Miranda House Nursing Home 08/06/05

Miranda House Nursing Home 01/02/05

Miranda House Nursing Home 21/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Key inspection report Care homes for older people Name: Address: Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 2 5 0 3 2 0 1 0 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 56 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 56 Information about the care home Name of care home: Address: Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH 01793854458 01793853951 qualitycarewilts@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Quality Care (Wiltshire) Ltd Name of registered manager (if applicable) Mrs Gillian Gray Type of registration: Number of places registered: care home 68 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: No more than 2 persons not less than 50 years in receipt of day care at any one time. Persons less than 45 years of age may not be accommodated. Date of last inspection Brief description of the care home Miranda House is able to provide personal care and nursing care for up to 68 adults. These may be people with dementia or other mental health problems. Miranda House is in Wootton Bassett, near Swindon, Wiltshire. It opened in 1996, and was extended in 2005. The purpose built accommodation is on two floors, with passenger lifts between them. Most bedrooms have en-suite toilet facilities. All bedrooms are currently used as single rooms. Baths and showers are provided throughout the building. There is also a range of communal space, including lounges, dining rooms and a conservatory. There is a garden and several parking spaces at the front of the Care Homes for Older People Page 4 of 56 0 6 0 4 2 0 0 9 10 10 Over 65 68 68 Brief description of the care home building. The fees start at six hundred and sixty eight pounds, with higher rates reported to be charged for people with an increaced dependancy. People are able to request copies of the homes Statement of Purpose and Service Users Guide. Care Homes for Older People Page 5 of 56 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, surveys were sent out to residents, their relatives, staff and external professionals who visit the home, and five were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. The homes file was reviewed and information obtained since the previous inspection considered. The home also submitted an Annual Quality Assessment Audit (AQAA). This is their assessment of the quality of their service provision. It also provided numerical information on services provided. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what areas we should focus on when doing the inspection. The site visit was performed by two inspectors and a pharmacist inspector. These people are referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The site visit took place on Thursday 25th Care Homes for Older People Page 6 of 56 March 2010, between 9:25am and 5:45pm. The visit was unannounced. Mrs Gray was in charge of the home when we commenced our visit and the area manager arrived at the home during the inspection. Mrs Gray and the area manager were available for the feedback at the end of the inspection. During the site visit, we met with a range of residents and also observed their care. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for several residents, including a resident who had recently been admitted to the home and looked at specific records relating to certain aspects of individual residents nursing and care. As well as meeting with residents, we met with registered nurses, carers, housekeepers, a laundress, the chef, the maintenance man and the administrator. We observed a lunchtime meal. We reviewed systems for storage of medicines and observed a medicines administration round. A range of records were reviewed, including staff training records, staff employment records, complaints records and maintenance records. Care Homes for Older People Page 7 of 56 What the care home does well: What has improved since the last inspection? What they could do better: Information for people prior to admission, particularly in relation to fees, continues to need development. Assessments of nursing and care needs prior to admission needs to be completed in more detail and take into account research-based evidence. Care plans would benefit from further development to include all of a persons needs. Care plans need to be revised when a persons needs change. They need to be precise and clearly describe actions to be taken to meet individual peoples needs. Where records are made of peoples changes of position, they must be completed contemporaneously. All records need to be dated. Improvements are needed in the management of administration of medicines, this includes record-keeping, staff training and taking into account current guidelines relating to medicines and their management. Care Homes for Older People Page 8 of 56 Residents dignity would be improved by ensuring that underclothes clothes are not used communally, are in a good condition and that staff use peoples own names when addressing them. Residents needs to be offered a choice of meals and drinks, rather than having one set menu choice. Catering staff need to be trained in provision of diets to elderly people and people with dementia. Old cups and place mats should be replaced. The home needs to ensure that it can evidence that all complaints have been fully investigated and they continue to need to document all informal concerns raised by people. Many improvements are needed in the environment. Redecoration is indicated in many areas. Furniture and equipment needs full cleaning and replacement in some cases. More equipment is needed to meet the needs of people with a disability, including hoists, full body slings and hairdressing equipment. The home needs to address a range of areas in relation to prevention of spread of infection, including provision of single use hand cleansing and drying, correct management of potentially infected items and cleanliness in the laundry. Old and disused items from the home need to be disposed of from the garden areas. Staff files need full review, to ensure that the home has all the information it needs to ensure staff have been safely recruited. Training plans need to be developed to provide staff with the skills base that they need to meet residents needs. Management systems need improvement, particularly in ensuring that the home addresses our requirements and recommendations from previous inspections. Systems for audit of quality of service provision need strengthening, including reports from the providers of their visits to the home. The home needs to ensure that they always inform us of all matters as required under our regulations. Some areas relating to health and safety need development. This includes drawing up of an infection control policy which reflects the home situation, timely up-dating of the homes fire risk assessment, revision of risk assessments relating to the bathing or residents and more frequent audit of health and safety arrangements in the home. 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 56 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 56 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will not to be given all the information that they need prior to admission. People would benefit from more detailed assessments, which are promptly performed and take national guidelines fully into account. Evidence: In their AQAA, the home reported that they provide individuals with brochures and information packs, they also give people additional information about services provided verbally, on request. They report that they are planning to review their service users guide, particularly in relation to outlining how they meet the needs of people with dementia. They did not comment specifically on their admissions process but did comment among other areas, on their staff training programme and work towards developing links with the local community. We looked at information given to residents and their supporters. We were given a statement of purpose dated December 2008. No action had been taken to address the Care Homes for Older People Page 11 of 56 Evidence: good practice recommendation we made that the statement of purpose should have information about how the home cares for people with dementia and those with mental health needs. We said that this should also include how peoples privacy and dignity is maintained. The statement of purpose made reference to people as being EMI, Elderly Mentally Infirm. There was very little information about how people were supported. Mrs Gray told us that the statement of purpose was published by the provider and she did have some input. The information about contacting us was not up to date and showed contact details of the previous regulator. Little action had been taken to address the requirement outstanding from the last two inspections that people must be provided with information about breakdown of their fees. This requirement was made on 7th October 2008 and is still not fully met. We looked at the contract which did not give information about fees. It stated that people with medium or higher need would have increased staffing costs. There was no information as to what these were. The area manager told us that information would only be given to people if they requested it; this fact was not advertised. They reported that if people were funded by a local authority, the home would sign up to their contract. We said that Regulation 5A sets out the information that was required to be made available about the fees. We are aware that the company as a whole is reviewing contracts across all the group but have not been informed by the provider either in their AQAA or by other means, of when this requirement will be addressed. We spoke with some visiting relatives to ask them why they had chosen this home for their family member. One relative told us they had heard good reports locally. The manager and several members of staff reported that most people chose Miranda House as they lived locally and it was easy for people to visit. Mrs Gray told us that she normally carried out the pre-admission assessments, although the nurses were also involved in these assessments. A registered nurse reported to us on how they took into account written and verbal information from previous providers when they made assessments. We met with a recently admitted resident, reviewed their records and discussed the persons needs with staff. The persons pre-admission assessment noted key areas such as difficulties in swallowing, the presence of a pressure ulcer prior to admission and an infection they had in hospital. However other key areas were not completed in such detail. For example their pre-admission assessment stated that they wore glasses, without stating what they wore them for. It was noted that the person needed to use a certain prescribed appliance, but there were no records relating to the detail of the type of appliance or when it needed changing next. The assessment did not Care Homes for Older People Page 12 of 56 Evidence: state if the infection they had had in hospital had now cleared. Twenty four hours after the persons admission, no assessments of risk had been performed, including risk of pressure ulceration, manual handling risk or dietary risk. Bodies such as the Health and Safety Executive (HSE) and National Institute for health and Clinical Excellence (NICE), state that such assessments for risk should be made a short period of time after admission or need for such assessment becomes evident. The persons ulcer had been photographed but the photograph had not been dated and nor had the preadmission assessment itself. Such records need to be dated, to provide evidence of when they were made. At the last inspection of 6th April 2009 we made a good practice recommendation that all subsequent assessments after admission contain sufficient attention to detail to help ensure that peoples dignity is respected. We saw that members of staff were working with people in a respectful and dignified manner. However the care plans and assessment documentation made little reference to dignity and privacy. Care Homes for Older People Page 13 of 56 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will generally have their health and personal care needs met, however as not all information relating to their individual needs is accurately documented, they may be at risk of having some of their needs not being met consistently. There were generally adequate arrangements for managing medicines but the inspection identified particular weaknesses to attend to so as to reduce the potential risks with medicines for people living in the home. Evidence: In their AQAA, the home report on their good working relationships with external health care professionals. They report that care plans identify peoples needs, that the qualified staff ensure that peoples well-being is monitored and that people are assessed to monitor their mental and physical well being. They report that they evidence that they meet standards for health and social care, among other areas, from their regular reports by a senior manager and their monthly review of care plans. They report that during the last year, they have worked towards person-centred care planning, with care plan reviews being carried out in a timely manner. Storage and security of medicines have been improved by the provision of larger clinical rooms. Care Homes for Older People Page 14 of 56 Evidence: A relative commented to us in their survey that the home were very respectful to clients and family and that they were very proactive in any medical situation. At the last inspection we made a recommendation that relatives should be informed about and changes for people with dementia as they would be involved in their best interest decisions where appropriate. We spoke with four relatives who told us that they were regularly kept informed about their family members care and support needs. One relative told us that they regularly attended reviews. However two relatives told us that the home was varied in the information that was given to them. They also told us that they had not had a review at the home, save the review conducted by the funding authority. One of the relatives we spoke with during the inspection told us I am very pleased with the care. The staff are very friendly and my [relative] is always well presented in matching clothes. I go to reviews and they ring if my [relative] isnt well. They let me know if the doctor changes [my relatives] tablets. XX still sees their own doctor. Several members of staff told us about how they found out about meeting residents needs, reporting on the handover at every shift, where all staff were involved. One carer described handovers as thorough and that they were not rushed. A registered nurse reported that they were concerned about confidentially when giving report as they no longer had a private area to discuss individual residents needs and did this in a corridor area. A registered nurse reported to us on how good care staff were at informing them of any change in a residents condition, such as a skin tear or a bruise. A care assistant reported that they were allocated residents to care for on a day-byday basis, in the allocation book. They also reported on the key worker system and how they concentrated on their key residents and tidied their drawers. One of the nurses told us that peoples care plans were reviewed every month. They told us that the home intended that key workers should be more involved in writing and reviewing care plans and write in the daily reports. A carer informed us that one resident was given care on a 1:1 basis. A carer reported that they appreciated this role being rotated between staff, so that staff did not become too stressed and so could continue to give the person good care. We visited one person who we could not communicate with. We looked at their care plan for communication. There was information about a cognitive impairment. Members of staff had to make sure that the person had their glasses on, use eye contact and simple language. The plan stated that members of staff should talk about animals to engage the person in speech and to ask closed questions so that the person could answer yes or no. The person was described as having a good memory Care Homes for Older People Page 15 of 56 Evidence: for past events. The person was described as withdrawn when angry. The care plan had been reviewed monthly. Not all care plans were so clear. A person had a care plan about frequent requests to go to the toilet which stated that they were to be assisted to the toilet regular. This is not clear. One person had guidance on moving them from their bed to a chair. The care plan stated that they were sometimes resistant to care. The guidance was give reassurance. We thought that these statements gave no information as to what was meant. Another persons care plan stated slightly confused at times. There was no information as to what the person was doing for staff to come to this conclusion, or whether there were any indicators or patterns. Some people did not have care plans when indicated. A resident had a complex flexion contracture, but there was no information how their personal care and cleanliness was to be performed in the light of this contracture. Two people had prescribed creams but there was no information on when and where on their body these creams were to be applied. A person had visible lesions on their lower legs but there was no care plan about their management and no records of these lesions in their daily record. Another persons daily record showed that a wound dressing had been renewed but it did not state what the wound had been re-dressed with and there was no wound dressing care plan. Not all care plans had been up-dated when indicated. A person had an assessment for risk of pressure ulceration which had not been reviewed when their condition deteriorated and they were less mobile and their risk of pressure ulceration increased. We observed that one person had a care plan relating to their breathing, which stated that they did not have any difficulties. Other records showed that they had had needs relating to recurrent chest infections for a period of time, their breathing care plan had not been up-dated to reflect this. Many of the frail people had their conditions monitored on a regular basis, via fluid, food and turn charts. We observed that food and fluid charts were completed at the time the resident was supported. Fluid charts were totalled every 24 hours. The information obtained by such records would provide a good basis for evaluation of care plans and responses to interventions by staff. Turn charts indicated that people were having their positions changed to prevent pressure ulceration, however they were probably not accurately completed. All the peoples turn charts we looked at stated that they had been turned at night at the same time, 10:00pm, 2:00am and 6:00am. As it takes time to turn a person who needs their position changing and there were many residents who needed their positions changing, it would not be possible for Care Homes for Older People Page 16 of 56 Evidence: all people to be turned at the same time. We also noted similar observations during the day. When we visited a person at 11:55am, they were lying on their left side, however the only record on their chart was for 8:30am, which stated they were on their back. When we returned to the person at lunch-time their turn chart had been added to, stating they had been moved to their left side at 11:00am. We observed that another resident was lying on their right side at 1:50 but their turn chart did not show that they were placed on their right side until 2:45pm. Turn charts need to be completed contemporaneously, to ensure that the home can evidence that a person is receiving the care that they need to prevent pressure ulceration. In the AQAA the home stated that there were three people whose first language was not English. We asked how members of staff communicated with them. Mrs Gray told us that one person who spoke Polish had the benefit of Polish staff to communicate with. We thought that it would aid that persons quality of life if other members of staff could use key Polish words that were written in the persons care plan. Action had been taken to address the good practice recommendation we made that people with dementia should have a record of when elimination occurs and when they are bathed; to help ensure their health and wellbeing are adequately addressed. We saw evidence of this in care plans and continence charts. We also made a recommendation at the last inspection that there should be an individual timing in the care plan for assisting people to the toilet, as this may vary, to encourage continence and promote dignity. We saw that individual records varied. However we saw that staff were respectful when supporting people to use the toilet at different times of the day. Mrs Gray reported the home had links with the occupational therapy service and that occupational therapists had completed an assessment on a person who had complex seating needs. A registered nurse reported that they had contacted the tissue viability nurse about a person who had been admitted with a wound. A relative reported on the supports from the psychiatric service for their relative, organised by the home. Mrs Gray told us that the home had a contract with one of the surgeries and a GP would visit the home once a week to discuss their patients care needs. She told us that local people could also continue to be registered with the GP who had visited them at their own home. A relative commented that their relative was always lovely and clean and that staff always try and dress XX in clothes that match-up. We met with one resident who had their name in large letters written on their slippers. We thought this was institutional. The resident was also in need of having a shave. They were walking Care Homes for Older People Page 17 of 56 Evidence: along the corridor asking for someone. A member of staff immediately came and supported them to find out what they wanted, chatting and engaging with the resident in a very positive manner. We did observe one instance where personal care was provided to a resident with the door to their room being left partly open, so that a person would have been able to see in if they were passing the room. We observed that many staff did not use residents own names and used generic terms of endearment such as saying whats wrong my darling, alright my darling, young fella, young lady or gorgeous. As well as sounding institutional in tone, in homes which specialise in dementia care , it is important for people to be called by their own names, to support them in a sense of their awareness of self and enable them to understand that it is them who is being talked to. As a part of this key inspection one of our pharmacists specifically examined some of the arrangements for the handling of medicines. We looked at some stocks and storage arrangements for medicines and various records about medicines. We spoke to the manager, two registered nurses, a carer and the regional manager. We visited some bedrooms, spoke to some people who lived in the home and at lunchtime saw one of the nurses giving some medicines to two people who live in the home. At the end of the inspection we gave some feedback to the manager and regional manager. Registered nurses were responsible for administering and managing the arrangements for medicines in this home. The manager told us that there was a system to check the competence with medicines of their own nursing staff and we saw a chart with training information that helps the manager to track what training staff need and when. Unfortunately one of the nurses on duty on the day of the inspection who had worked in the home for about three months had not yet had medicine training or competence assessment. The manager was arranging this immediately and told us she was also arranging with the supplying pharmacy to run a medicine refresher course for all nurses in the home. At the time of the inspection the nurses told us that nobody living in this home was able to self administer their medicines except for one person who with support of the staff dealt with an inhaler themselves. We saw that there was a care plan and risk assessment in place for this but pointed out that the medicine administration chart should also indicate this was the case. The medicine policy we were given did not include any information about people living in the home being able to self administer their medicines if a risk assessment showed this would be safe for everyone. It would be good practice to include in the care plans if people had particular preferences firstly about if they wanted to self administer their medicines and then their choices about Care Homes for Older People Page 18 of 56 Evidence: the way in which they preferred the nurses to deal with their medicines so as to respect their privacy and dignity. People living in this home were therefore totally dependent on the nurses for the administration of all their medicines. When we arrived people had already taken their morning medicines on time and at lunch time we saw a nurse giving the medicines at the right times. Since the last inspection there are more medicine trolleys to keep medicines safely and we discussed with one of the nurses about safe practices when administering medicines. Rearranging the medicines on the two ground floor trolleys would help accepted safe procedures to always be followed rather than walking around with the medicines for one person in a small pot. The nurse on the first floor told us that the way they had arranged the two trolleys meant that these were always used when they take any medicines to each person. There were arrangements for keeping records about medicines received, administered and leaving the home or disposed of (as no longer needed) for each person. The pharmacy that dispensed the medicines for people living in the home provided printed medicine administration charts each month to help with keeping the detailed medicines records needed. Accurate, clear and complete records about medicines are very important in a care home (particularly where staff are totally responsible for the medicines) so that people are not at risk from mistakes because of poor records about medicines and so that there is a full account of all the medicines the home is responsible for on behalf of the people living here. We looked through a sample of the medicine records in use and found that these were generally up to date, mainly indicated the medicines people needed were in stock and staff had given these according to the doctors directions. There were some exceptions and some points for attention. For three people there were five gaps on the medicine records in use since 15th March 2010 so it was not clear if people had received these medicines. In two instances the tablets had gone from the packs for that day and time. For two people duplicate charts seemed to be in use with different entries on each so we did not know which was correct. In one case the tablet was still in the pack. For another person the medicine chart was signed as though the tablet was given but this was still in the pack. We tried to audit some tablets as the records included a stock count of the number of tablets carried forward to the new chart. We counted four more tablets than the records showed; this indicated that the records may not be accurate. The home have recently carried out an investigation about some unaccounted tablets and found poor Care Homes for Older People Page 19 of 56 Evidence: record keeping and inconsistencies in the recorded stock balances carried forward each month. We had not received a copy of this report at the time of the inspection so we talked to the manager about actions she was taking to try and avoid this happening again and questioned if the police should be notified. Some of the records we sampled needed to include what quantity of medicine was administered where the direction was for a variable dose (5ml to 10ml for example). The medicine record for one person was printed for soluble tablets and staff had signed as giving these. The pack of medicines on the trolley were not the soluble tablets but had the same active ingredient. The nurse told us this person would be able to take these tablets but was going to contact the pharmacy to find out why this had happened. The records seemed to indicate this medicine had been out of stock from 15 to 19 March 2010 although the meaning of the code letter M on the medicine chart was not clear. Doses of insulin on some medicine records were abbreviated as IU rather than using the full word units as is accepted best practice. This abbreviation is known to be a cause of mistakes sometimes with insulin. The manager must remind all staff about this. The pharmacy had printed known medicine allergies on the record charts and with each chart there was also information about allergies. In many case this was noted as none known. It is good practice to always have an entry like this on the medicine chart as well as this indicates this important information has not been overlooked. The pharmacy should be able to assist with this. For some people there was additional printed information with the medicine charts giving extra guidance to the nurses about the use of medicines with a direction to use when required or with a variable dose. For other people this information was not in place. One person was prescribed a sedative type medicine to give three times a day when required. Since 15th March 2010 the medicine records indicated this was given three times every day but there was no guidance about when and why this should be used and the reason the nurses had administered this regularly. The manager needs to make sure that such guidance is in place for any medicine where a variable dose is prescribed or with a when required instruction. The provisions of the Mental Capacity Act 2005 must be taken into account particularly if people lack capacity to understand, ask for or consent to their medicines. Having this sort of guidance helps to make sure that there is some consistency and agreed actions to meet the peoples individual needs. Care Homes for Older People Page 20 of 56 Evidence: We looked at the arrangements for dealing with anticoagulant medicines where there is specific national guidance to follow. Regular blood test results and doses were confirmed in writing from the hospital and this information was kept with the medicine records so that the nurses could readily see what dose they had to give. The medicine charts were clear about the dose to administer. The standard yellow anticoagulant record book was not in use and staff spoken to did not seem aware about the guidance from the National Patient Safety Agency (this can be obtained from www.nrls.npsa.nhs.uk). Similarly lithium tablets were prescribed and this is another treatment where there is new specific national guidance to follow. (This can be obtained from www.nrls.npsa.nhs.uk) We saw that there were regular blood tests recorded in the care plan to monitor the treatment. A standard record book for this treatment is now available and should be put in place. A specific care plan about more complex treatments like this should be considered. Improvements were needed in handling and recording arrangements for medicines applied to the skin (such as creams, ointments, lotions). There were not always clear, consistent or up to date records for all of these. There needs to be a defined way to make sure that these treatments are used correctly, that staff have clear information about this and that records clearly demonstrate what treatment has been provided. We have published information about this on our website (www.cqc.org.uk Pharmacy tip 9 - Administration and recording of creams and nutritional supplements). We could not find in stock a cream prescribed for one person so it is probable that a new supply was needed. The nurse was looking in to this during the inspection. We found a number of containers of creams where there was no opening date so it was not possible to regularly replace items with new containers as is needed to reduce risks from contamination. The pharmacy can provide information about recommended periods for using medicines after they have been first opened. A cream in one persons bedroom belonged to another person. The manager needs to be sure that the way in which some containers were kept in bedrooms is safe for everyone in the home. The medicine policy could usefully include information about all of this. The right arrangements were in place for storing and managing controlled drugs. Generally two nurses witnessed the administration of any medicine in this class. It is important that if another member of staff who is not a nurse has to be used as a witness they are suitably trained to understand what they are witnessing. The use of a witness is an important role and we provide more information about this on our website (www.cqc.org.uk). In summary it is intended to reduce the possibility of an error occurring. To be effective, the witness must understand what the nurse Care Homes for Older People Page 21 of 56 Evidence: administering the medicine is doing and therefore needs the appropriate level of training. Separate records were in place for checks of the stock at each change of shift. Our checks of these medicines in stock agreed with the record book. The heading on each page of the record book should also include the name of the person this page refers to. The manager must confirm that the correct fixings have been used to secure the cupboards when they were moved to the clinical rooms. We provide more information about this on our website (www.cqc.org.uk). There were suitable arrangements for the disposal of these medicines; there was a used denaturing kit in one cupboard that now needs sending to the waste contractor. The arrangements for storing medicines on both floors have changed since the last inspection with more space and privacy provided. We were concerned that on the day of the inspection the temperature in the ground floor storage area was too warm to keep medicines and that the daily temperature records indicated this was common. The regional manager and home manager were taking action during the inspection and told us at the end of the inspection there was a potable air conditioning unit to install. There was a separate locked medicines fridge on each floor; the temperature in the fridge on the ground floor showed this was not working properly (too warm) although had been all right when the temperature was recorded at 8am on the morning of the inspection. The temperature control was turned down during the inspection and the manager was checking if this corrected the temperature, otherwise an alternative fridge would be used whilst a new medicine fridge was obtained. The temperature record chart could usefully include another column to confirm the actual temperature at the time of the daily check as well as the maximum and minimum temperature which serves to indicate the range since the thermometer was reset. We noticed that insulin vials that had been opened for use had a date noted on the pack but were stored in the fridge. Staff need to carefully follow the manufacturers directions about storage of insulin; in one case the direction was specifically not to store in the fridge once the vial is in use. Opened containers of eye drops had dates of opening written on the pack and the ones we looked at were all within date. Not many other medicines on the trolleys had opening dates. It is good practice to write the date of opening on any pack of medicine (except those in the monitored dosage system packs) as this provides a useful additional way to audit medicines and to help make sure stock is properly rotated. We saw that counts of medicines in stock at the beginning of each month were recorded but the recent internal investigation was critical about the accuracy of these records. There was a daily audit sheet for nurses to complete and the manager told us there were other audit systems in place. The effectiveness of audits should be reviewed to Care Homes for Older People Page 22 of 56 Evidence: make sure that issues such as we picked up at this inspection are addressed before they pose a risk to people in the home. The regional manager gave us a copy of the company medicine policy and procedures. These need revising to make sure that all aspects of medicine management within this home are covered and that references to codes of practice and controlled drug storage are up to date. This report includes examples of issues that should be addressed in procedures and clear direction given to staff. The manager needs to provide staff with clear up to date information about how the company expects the staff to manage medicines safely on behalf of people living in the home. This should be readily available so that nurses can easily refer to them. Nurses had provided sample signatures and initials on a list so that it was possible to tell who had been responsible for any medicine administered. Care Homes for Older People Page 23 of 56 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. Residents will be supported in their daily lives and social activities, including at mealtimes. However residents are not supported in exercising choice, particularly at mealtimes. Evidence: In their AQAA, the home reported on their weekly plan of activities and that they supported people who were unable to engage in group activities by one to one support. They reported that activities staff hours had increased and that care staff were encouraged to be involved. They reported that they were seeking to increase trips out and about their gardening club, where they grow their own herbs and some of their own vegetables. They did not comment on meals provision in their AQAA, including the fact that a choice is not provided at mealtimes and how the home plans to address this. There was a diary of activities published on one of the notice boards. It showed a list of activities for the mornings and afternoons, Monday to Sunday. There were posters for an Easter raffle and a cake sale on the front door. Mrs Gray told us that the activity coordinator was on leave, so we were not able to discuss activities in great detail. Mrs Grey told us that she had recently appointed a part time activity coordinator, so that Care Homes for Older People Page 24 of 56 Evidence: activities could be provided seven days a week and during the evenings. We saw that staff were doing different activities with groups of people in the sitting rooms. Mrs Gray told us that large group activities did not work; staff tended to do things with one or two people. We saw one female resident having their nails painted. One person was having a newspaper read to them. Other people were sitting in small groups doing colouring, crafts and board games. In one sitting room the television was on with the sound turned down and music coming from a CD player. An another sitting room we observed a care assistant sitting with residents at table, there were lots of different objects for the residents to feel and handle. The care assistant was supporting and encouraging them in doing this. The care assistant had good eye contact with residents. Some residents were sitting quietly washing television. Some of the reception on some peoples televisions and in one sitting room was not as sharp as it should be. Mrs Gray told us that during the summer part of the courtyard had been fitted out as a beach. A group of donkeys had visited the home during this time. There were photographs of the event on some of the notice boards. Mrs Gray told us that peoples taxi tokens would be pooled so that people could go by taxi to a local garden centre. We had received information that the conservatory and snoezelen were never used. We looked at the room described as snoezelen room. A snoezelen room is a multi sensory room normally used by younger people with disabilities. There were a few items of equipment, a few chairs without seat cushions and a sideboard with very little in it. The room was not identified or advertised as somewhere where people could access when they wanted to. The large conservatory had tables and chairs and a few plants. Mrs Gray, in answer to our question about its use, told us that it was used for some activities, but not for meals. Mrs Gray told us that events were being held to raise money for a sensory garden and raised flower beds. She told us that the home would apply to the company for funding for major projects. Mrs Gray told us that the wooden building in the courtyard, previously used as a smoking area, had been re-designated as a craft and painting room. It was used more in the summer as it had no heating. Seating and parasols had been provided for people who smoke outside. We met with one person who used this facility. One relative told us that their relative had French windows to their ground floor bedroom but did not sit out last summer. They told us that members of staff never opened the windows so their relative could be pushed outside in their wheelchair. Care Homes for Older People Page 25 of 56 Evidence: One resident told us that they were frightened of residents of the opposite sex coming into their bedroom. We saw that there was no lock on their bedroom door. There care plan stated that the resident put furniture against the door to prevent entry. There was little information about how this need was being addressed. The guidance was that the person was to be given reassurance. We asked the person whether they had been asked about their preferences of the gender of members of staff who provided their personal care. They told us that they had no choice. There was no information in the persons care plan about their preference when intimate personal care was provided. One person described the meals as alright, another theres loads of lovely food here and another that if their relative was hungry, they would be given seconds. Two relatives told us they liked their visit to include a mealtime so they could support their family member to eat their meal. They told us that the chef provided their family member with an alternative if there was something on the menu that they did not like. Another person also told us they would be given something else if they did not like the meal. A change to the homes menu for that day was advertised on one of the notice boards. We thought that it would only be seen by anyone who knew it was there or regularly looked at the notice board. The change was not advertised in either dining room although staff did know about it. We asked people what they were having for lunch. Only one person told us what they had ordered. Another person told us that members of staff brought their meals to their bedroom because they did not like eating with other people. The lunch was minced beef, with broccoli, cauliflower and mashed potatoes; with raspberry and coconut sponge for pudding. There was no choice of dishes for any of the meals. There was also no choice of juice for residents if they wanted a drink with their meals. The chef reported that they developed the menus, with support from relevant others in the home. We discussed provision of choice for meals with the chef. The chef was keen to look at this area further, particularly different ideas about how choice could be provided to residents who had dementia and other forms of memory loss. We advised them that homes which specialise in dementia care do find that provision of choice for residents with short-term memory loss is possible and that there are a range of different methods of achieving this, without incurring high wastage of food-stuffs. The chef had a good understanding of different residents individual specific preferences, for example one person had scrambled egg on toast because they did not want the main meal. Care Homes for Older People Page 26 of 56 Evidence: Everyone at the dining table was given a clothes protector bib. We asked two people why they were given to everyone. They told us that they did not want to spill food on their clothes. We saw that the bibs did not have individual names on them but were given from a pile on the side. Staff dished up the meal from a hot trolley. The vegetables were put on the plates as the meal was dished up. We observed that plates were portioned according to peoples individual appetites. The meal was well presented although the vegetables looked a little overcooked. Members of staff took the meals to those people who were eating their meal either in the sitting room or in their bedrooms. Members of staff sat down with each of those individuals who needed help to eat, chatting about the food and engaging them to eat. One member of staff greeted the person and said Oh look at that lovely mince and this is broccoli and potato. Staff were also observed to check the temperature of the meal before assisting a resident to eat. We observed that staff carefully observed residents who might lose concentration when they were eating, so as to support them in continuing to eat. We observed a member of staff taking a meal to a resident in their room. The resident was asleep. The member of staff gently and gradually woke the person up and checked that they were fully awake before giving them their meal. Where people needed thickening agent in their drinks, staff showed a good knowledge of the consistency of the drink needed by each individual resident. We also observed that staff correctly mixed in the thickening agent, to ensure that it was fully distributed throughout the drink. We saw that the plastic cups on the morning hot drinks trolley were stained and looked unappetising. A similar observation was made at lunch-time The chef reported that they work closely with the nursing and care staff and that they received information on a monthly basis about individual residents changes in weight. As much as possible, they made up soup from raw ingredients, although they did use packet soups at times. They reported that they were keen to find out more about common diets for elderly people with dementia, including supporting people with weight loss and diabetic diets. All ordering of food-stuffs is done centrally by the provider. It was reported by two relatives and some of the staff, that when the chef was away, there had been occasions when residents had had to have sandwiches at lunch-time and fish and chips for supper. The chef agreed that this had occurred on more than one occasion. This is not satisfactory, as some residents may not like or be able to Care Homes for Older People Page 27 of 56 Evidence: manage sandwiches and many residents due to swallowing problems would not be able to manage a meal like fish and chips. Care Homes for Older People Page 28 of 56 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has procedures to ensure that people are safeguarded. Residents and their supporters need to know that any concerns or complaints raised will be logged and fully investigated. Evidence: In their AQAA, the home reported that all complaints are logged and investigated and responded to in accordance with the providers procedure. They report that their evidence to show that they do this well can be found in their complaints log. They also report on training in protection of vulnerable people for staff. We asked four relatives about whether they had been given information about the homes complaint procedure. Two relatives told us about concerns that they had taken to Mrs Grey who had addressed the issues to their satisfaction. All four of the relatives told us that they were confident that management would address any issues that they had. Two of the relatives told us that they had been given information about the homes complaint procedure when their family member had originally moved in. One relative told us I go and see [Mrs Gray and deputy manager] and they will deal with it. Another relative reported on their good rapport with staff. Certain matters were known about by the manager and staff such as reports of shrunken jumpers, inadequate or slow maintenance, unsightly rubbish being left on site. There was no documentation in relation to this. This indicates that no action had Care Homes for Older People Page 29 of 56 Evidence: been taken to address the good practice recommendation we made that all verbal concerns and the actions taken to resolve them be recorded. We also said that a written reply to relatives about the outcomes of any concerns should be completed. We saw that there were some letters to us in the complaint file in response to concerns that people had told us about. There was no record of the homes investigations into the concerns. For example a person was documented as reporting anonymously on poor English language amongst some staff, there was no outcome documented. We looked at letters to complainants, there was no evidence of an investigation into the complaints on file, just a response letter, so there was no basis to show why the investigation has reached this conclusion. Certain matters were known about by the manager and staff such as reports of shrunken jumpers, inadequate or slow maintenance, unsightly rubbish being left on site. there was no documentation in relation to this. We asked members of staff if there was a whistle blowing procedure. One member of staff told us that they would whinge to [the manager]. We can go to one of the nurses. The manager has been involved in making safeguarding referrals in accordance with local procedures and we are aware that they have cooperated in full with the multi agency process. Clear records relating to one particular report were inspected. We asked different members of staff, including a laundry person and a domestic what the procedure was if they observed or were told about potential abuse of people who use the service. They were all quick to tell us about the local safeguarding adults procedure. The training matrix showed that 10 members of staff had received safeguarding training in March 2009. Care Homes for Older People Page 30 of 56 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents basic needs will be met by the homes environment, however developments are needed across a range of areas to ensure their needs can be met and risks reduced. Evidence: In their AQAA, the home reported that they offer a secure, clean, welcoming environment with specialised equipment and that a maintenance person is employed. They felt that they could improve in the monitoring of response times to general repairs. They report that during the past year, they had secured the clinical and general rubbish area and introduced new cleaning schedules. At the last inspection we recommended that where some people had bare bedroom walls, they were offered a choice of accessories to improve their environment. We saw that most of the bedrooms we looked at had peoples own personal items and photographs. We had been given information that scarves and handbags had been tied to the rails in the corridors. We were told that they became dirty, frayed and destroyed when people touched them. Mrs Gray told us that these items had been placed around the building following guidance from a training course on dementia and that the scarves and other items were put around the home as items of interest for people. She went Care Homes for Older People Page 31 of 56 Evidence: on to say that sometimes relatives found this difficult to understand. Mrs Gray told us that she intended to provide a session from the National Association for Providers of Activities to Older People for relatives. We saw that peoples clothing returned from the laundry was as risk of being soiled or removed because it was placed on the rails by their bedrooms. Mrs Gray told us that this was placed outside their doors to avoid going into the bedrooms and wake people up. Mrs Gray showed us some wall hangings which people had made. They had pockets filled with different items made of material for people to look at. We said that some of the pockets were not accessible as they had been placed above eye level. Memory boxes had been put on peoples bedroom doors. These had small items or photographs pertinent to the individual, so they may recognise their own rooms. The doors were also numbered and had peoples names written on them. Some action had been taken to address the good practice recommendation we made that people who may be unable to tell staff that they are too hot, have the room temperature monitored, and that air conditioning is provided when necessary. We saw that the handyman had obtained a dehumidifying/air-conditioning unit which he was unpacking. A person commented in their survey that larger maintenance jobs appear to take a very long time to get repaired. Another person also commented about maintenance, reporting it seems to be one thing after the other going wrong and the time to put it right is too, long why do things take so long when they have their own maintenance force. We noted that the minutes of the staff meeting echoed this, with staff reporting concerns on the length of time taken for repairs. We saw that some areas of the home would benefit from refurbishment and redecoration. There were some vertical cracks in the walls of the back stairs leading down to the laundry area. A sitting room had a dried-on vertical mark giving the appearance of dried-on liquid, which ran down the wall and over an electrical socket. Many of the bedrooms showed need for improvement. There was damage marks on some walls and door frames from wheelchairs and beds. One bedroom had splash marks on the walls. Some of the bedrooms were fitted with linoleum rather than carpet. Mrs Grey told us that the corridors in the older part of the building had not been re-decorated for some time. The handyman told us that they had just returned from a period of time off. They told us that the handyman from a nearby home had attended to emergencies in their absence. They showed us the maintenance book where members of staff recorded things that needed attention. The handyman told us that one of the carers helped them with painting and redecoration of the home. They had started work on some of the empty bedrooms. Care Homes for Older People Page 32 of 56 Evidence: Some of the wardrobes in peoples bedrooms were marked and had ill-fitting doors. Some peoples chest of drawers were marked. We thought that these items belonged to the home rather than individuals as they were all the same make. We observed a range of deteriorating equipment and furnishings. A resident was sitting in a fabric chair in a sitting room, which a carer reported belonged to the home. The fabric was torn in places, with the undersurface showing and there was visible staining on the fabric. We observed several bed side tables with visible chips out of them, several safety rail protectors with holes in them and some of the linen bag skips had lost their plastic coating, with the under-surface showing. There were areas in some of the bathrooms and toilets where gaps had appeared in the floor covering, exposing the adhesive, making it difficult to look clean. We had been given information that the bedrooms were not properly cleaned and the beds were never cleaned underneath and the pictures were never dusted. On our visit we saw that parts of the home were generally cleaned to a good standard, including under the beds and the undersides of toilet surrounds. We observed a cleaner very carefully damp-dusting round pictures in the corridors. However, this was not the case throughout. In a sitting room we observed two cloth-covered chairs with staining down the sides where residents sometimes rested their hands. The snoozelum room was dusty and there was a used cup on a table, which was stuck to it. We had been told that the dining area was not clean, the undersides of tables were not cleaned and the home smelled. We did not note any unpleasant smells at any time during our visit. We did however observe that the undersides of the dining room chairs and tables had deposits of sticky matter and palpable debris. The place mats looked worn and had faded. Some of the safety rail protectors showed dried on liquid-type deposits, presumably from drinks. Equipment and furniture for residents must be clean and intact to ensure that they can be cleansed. This will prevent risks to cross infection and uphold residents dignity. We spoke with three housekeepers. One of the housekeepers was knowledgeable on the importance of regularly changing mop heads and the homes colour-coding system to ensure that clean and dirty areas used different equipment. The senior housekeeper showed us the cleaning schedules. They told us they regularly checked to see that cleaning was carried out. The form was generic and not always fully completed. We saw that one form for cleaning a numbered toilet had information about cleaning a television. We thought that the form did not suit each identified task and this was probably why it was not being completed. We suggested that a suitable form was compiled to suit the tasks needing to be completed. The housekeeper told us that they had a schedule for ensuring that all the carpets were regularly shampooed. They said Care Homes for Older People Page 33 of 56 Evidence: it was difficult to keep up with cleaning all of the chairs. They also said they tried to limit shampooing the carpets in peoples bedrooms to lunch time as they would have to ask people to vacate their rooms at other times. We looked in some residents drawers in their rooms and observed that where residents had clothes named with name-tapes, that the name on the tape related to the individual. However where marker pens had been used, this was not the case. In one residents drawers, the name of a person had been crossed out of a pair of pants and the name of the person in the room added. Another pair of pants had the name on it washed out and another had a name of a person on it other than the person in the room. Many of the pairs of pants had no names on them. All of the pants in this persons room were in a deteriorated state, with in-grained staining, loose elastic and fraying of the fabric. In another two rooms, residents also had several pairs of deteriorated pants in their room with no names marked on them. The manufacturer of the pants was a type commonly used by ladies, so the home is not preventing the communal use of underclothing. This has the potential for risk of cross-infection, as well as not upholding a persons dignity. No action had been taken to address the good practice recommendation we made that sufficient hand washing facilities be provided for staff in the communal bathrooms, to promote infection control, some bathrooms had such equipment, but others did not. Where dispensers for such disposables were provided, they were not always filled, for example two sluice rooms had paper towel dispensers which had no towels in them. None of the en-suites had single use soap or hand towels. One of the residents we met with had an infection and another one had recently had an infection, with no evidence on their file that it was now clear. Older people, particularly those with dementia care needs, can have infections either without being aware or have them sub-clinically. There is a considerable body of research-based evidence that hand washing is the single most effective means of preventing the spread of infection. Therefore single use method of hand washing and drying need to be provided in all relevant areas, including residents en-suites. Other areas relating to prevention of spread of infection need improvement. We observed two foot-pedal operated sack holders for infected material. One was not clean and the other mechanism to open the bin did not function. We observed that four yellow bags for infected waste had been left on the floor in sluice rooms. We observed a care assistant using an old, cloth covered wheelchair to transport these bags to the disposal area. This is unsafe practice; clinical waste bags must always be placed in a clean, functional bin-holder, always be fully secured and be transported about the home is a safe manner, using equipment which can be fully disinfected. We Care Homes for Older People Page 34 of 56 Evidence: looked in one of the sluices. The position of the washer disinfector near to the wall, meant that the floor could not be cleaned to infection control standards. We saw a portable hoist being stored in one persons bedroom. We looked at the hoist sling to see if it was named for the person whose room it was. We saw that it was marked with a number. In another room, a hoist sling had been left; it had no number visible on it. We asked a member of staff whether people who needed to use a hoist had their own slings. They told us there were a number of slings which were used for everyone. In another part of the home, a carer informed us that there were two different sized slings for thirteen different residents to use. This meant that residents who needed hoisting frequently had to wait, as the sling they needed was in use. Residents need to be measured for slings to suit their weight and size. To prevent risks of cross infection, if they always need to use a sling, they must be provided with their own slings, which are marked for them and only used for them. We discussed equipment to meet residents disability and nursing needs and with staff. They reported that they had enough air mattresses and variable height beds. At the last inspection we recommended that adequate bathing facilities for frail people should be provided on each floor so that people have a choice of a bath or shower. One person took us to see their nearest bathroom. It had a fairly new specialised bath with integral hoist. They said they liked to have a bath once a week. A carer we spoke to on the first floor reported that they considered there were sufficient bathing facilities to meet residents complex needs, on that floor. We noted in the minutes of the Health and Safety meeting of 21st January 2010 that issues relating to lack of equipment were raised, with the response that XX explained budget restraints & how needs to be prioritised. We discussed the need for hoists to support residents, with staff. On one floor, it was reported that 13 people needed to use a full-body sling hoist, but there was only one provided on the floor. This meant that residents often had to wait, for example to go to the toilet, although there would have been enough staff on duty to support them in this, if there had been enough hoists. It was reported to us by more than one person that the hairdressing room only included hair washing equipment for people with moderate disability needs. If people could not use this equipment, the hairdresser used a flannel to damp their hair, or staff supported residents by washing the residents hair in the bath or shower room. This is clearly not satisfactory and the home needs to consider how they can ensure that all residents who wish to have access to hairdressing are enabled to do so. We did not see any means of regularly testing bath water temperatures so that people were not at risk of scalding. Members of staff told us that there used to be Care Homes for Older People Page 35 of 56 Evidence: thermometers and records in each of the bathrooms so they could test and record bath temperatures when bathing people. The handyman showed us his record of monthly testing of hot water in bathrooms. There was a risk assessment for hot water dated April 2009. It stated staff ensure correct temperature for service users bath/shower. There was no information of what this should be. The level of risk was assessed as low. This does not reflect what is reported by the Health and Safety Executive. We asked the handyman about the maintenance of shower heads to reduce the risk of legionnella. The records could not be readily located but the handyman told us that he soaked the shower heads in de-scaler every month. He also told us he checked the hot water temperature in all rooms every month. The record of the last test of March 2010 was in the maintenance log. We had been given information that there had been a failure in one of the central heating and hot water boilers earlier in the year when the weather was particularly cold. We noted that the minutes of the Health and Safety meeting on 21st January 2010 reported on issues relating to the heating system, which had first been noted on 24th December 2009. This means that the heating system in parts of the home had not been functional for an extended period of time. The home had failed to notify us under regulation 37 that this had happened as they are required to do. This is required so that we are made aware of how residents had been protected from risk. We had also been told that relatives had not been informed about this and some people had not had a bath for four weeks. We asked the relatives we spoke with whether they had been informed about the lack of heating and hot water. They said that because they were regular visitors, they knew about it when they came to the home. We asked members of staff how they had managed to support people with washing and bathing during this time. They told us they had had to carry jugs of hot water to people for them to have a wash and that bathing was impossible. Members of staff told us of their concerns about the safety issues of carrying hot water around the home. They told us that the kitchen staff had managed to do washing up because they had independent means of heating water and a dish washer. The handyman told us that they had bought free standing radiators so that peoples rooms could be heated. They told us that the issue only related to one wing of the home and that it had been fixed. We noted that all the radiators in the bedrooms that we visited were producing heat. All of the radiators we saw had been fitted with guards to reduce the risk of scalding should anyone fall against them. At the last inspection we recommended that there be an infection control procedure in the laundry for staff to follow to help ensure that all staff know about infection control Care Homes for Older People Page 36 of 56 Evidence: practice there. We inspected the laundry and observed that there were considerable deposits of dust and other items such as bits of cloth and plastic behind the machines. This is a risk as micro-organisms can live and grow in such debris. The detergent dispensers were on a wooden plinth, this was not wipable. The outer wall was not intact and so not wipable. The laundress reported on the alginate bag system for infected and potentially infected laundry and that staff followed the homes procedures on management of such laundry. All other laundry is not separated as source as is currently advised to reduce risks of cross infection. We looked at bedding and towels in one of the stores and in some peoples bedrooms. Some of the bedding was thinning and had a grey appearance. We thought some of the towels faded through frequent washing and had lost their nap. The area manager told us that these items were easily replaced with an order for new ones. A person commented in their survey that the home needed to clear the rubbish outside (large furniture items that are no longer needed). We had been told that the home used to have a gardener who had left and that the garden areas were untidy. We looked at the grounds, both at the front of the house when we arrived and from the windows in different parts of the building. Some parts were very overgrown but the front entrance was kempt. We saw that there were chairs, mattresses and a fridge outside by one of the fences. In another part of the garden we could observe broken bits of wood and a discarded metal trolley. Most peoples views from their bedroom windows had very little of interest. We thought that planting spring bulbs would have provided interest, particularly for those people with a dementia to remind them of the time of year. We asked the handyman who told us that there was a gardener who worked 3 or 4 days a month. The handyman told us that the discarded items would be taken away when they ordered a skip. Care Homes for Older People Page 37 of 56 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will largely be supported by the homes staffing, however there is the potential for risk as there is not full evidence that all staff have been safely recruited and trained in all areas relating to residents nursing and care needs. Evidence: In their AQAA, the home reported that they ensure staffing levels and skill mix, follow recruitment polices and procedures and provide mandatory training through E-learning and external providers. They report that in the next year, among other areas, they plan to reward staff who achieve National Vocational Qualifications and offer training to give their staff confidence and purpose. Mrs Gray told us that in the morning, there were six members of care staff and a registered nurse working on the downstairs floor and one registered nurse and seven members of care staff working upstairs. In addition there were two members of staff working in the kitchen, two laundry staff and four cleaners. Mrs Gray told us that there normally would be five cleaners, however one was on sick leave. Members of staff told us that working downstairs that afternoon and evening there were one nurse and four carers. We asked them whether they had support staff working with them and whether they had to do other duties as well as care. They told us that there was no housekeeper in the afternoons so they would have to manage any cleaning and some laundry. They told us that the chef did the washing up after supper. Mrs Gray Care Homes for Older People Page 38 of 56 Evidence: told us that some agency staff were used to cover some of the shifts. Currently they were recruiting for three registered nurses. The minutes of the recent staff meeting showed that staff reported increasing dependency among residents and that they felt that they could not keep on top of the workload. One person told us that members of staff answered their calls immediately, however another relative had told us If you ring the bell, no one comes. We observed that carers spent their time with residents, interacting with them in the sitting rooms. One relative told us You cant moan about the carers, they bathed half the residents as soon as the water came back on. A relative told us theres enough staff. They make us welcome when we visit Another relative told us theres been more staff recently. They are so patient and respectful.Members of staff engaged with people in a friendly and professional manner. We saw a few times when people had become anxious or distressed. Members of staff responded immediately to the person and established why the person was reacting in this manner. Members of staff were very supportive of people who could not make sense of what was going on. One relative told us there are so many foreign workers, the old people dont understand them, for example a Polish worker who cant understand what you are saying. We spoke with various different staff and observed their engagement with people who use the service. We found no evidence of lack of communication. One person told us that they had developed good relationships with members of staff and described the members of staff from overseas as lovely. We asked them if they understood what all the foreign staff were saying to them and they told us that they did. We looked at employment files relating to four members of staff. We observed that where a member of staff had been employed for a longer period, that the files did not appear to include all required information, such files were complex to audit because they were not kept in an orderly manner. We observed at least one instance when records relating to one member of staff were placed on a different member of staffs file. We advised that a full audit of staff files needed to take place to ensure that they did include all information and where a member of staff had been employed for a longer period, that file notes should be placed on file to document why certain documents, such as references or proof of identity were not available. We observed that one recently employed member of staff had no documentation relating to previous employment prior to 2008. Mrs Gray was reminded that a full employment history is needed, to include at least the last ten years of employment. Another member of staff had put only one referee on their application form and this related to their previous, not current employer. There was no evidence that the reasons for this Care Homes for Older People Page 39 of 56 Evidence: had been probed at interview. Registered nurses reported that they paired a new member of staff up with an experienced member of staff when they commenced their role. They reported that they relied on these senior staff to let them know how the new member of staff was progressing, including where they might need more support. The provider has a standard induction programme, which complies with guidelines. They also have an agency induction. Those seen had been dated and signed. In the information provided prior to the inspection, the home reported that ten members of the care staff had training to NVQ level two or above. This does not represent 50 of the care staff and the home needs to consider how this can be further progressed. A member of staff told us that they got to do loads of training, however they also reported that they did not like E-learning and preferred taught sessions. The area manager told us that the home does not have its own training budget and all the training was provided centrally by the company. In their information provided prior to the inspection, the home reported that only two members of staff had received training in malnutrition care and assistance with eating food. This is a low number considering the amount of supports residents were observed to need at lunchtime. We looked at the training records. There was little training related to the needs of people for which the home is registered; dementia and mental health. We asked members of staff what training they had had in these areas. They told us a member of staff from a sister home had done some training in mental health. Training in deprivation of liberty safeguards and dementia had taken place in house. Some members of staff told us they had received training in breakaway techniques from the health authority. This training is normally given to staff who work with people with learning disability and equips them to deal with behaviours that challenge. The training matrix showed that six staff had received training in skin and wound care in June 2009. We looked at two members of staffs individual training files. One member of staff had an individual learning plan with the last entries for September and October 2008. The other member of staff had undertaken E-learning in safeguarding, health and safety, discrimination awareness, fire protection, first aid, food safety, customer care and moving and handling. A member of staff told us about recent training they had undertaken. They said they had NVQ Levels 2 and 3. They said they had undertaken training in moving and handling and infection control. Care Homes for Older People Page 40 of 56 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. Residents will be supported by some of the homes management systems but these need developing both in relation to health and safety and quality audit, to fully ensure the health, safety and welfare of residents. Evidence: In their AQAA, the home commented that the manager had been in post for 14 years and holds the Registered Managers Award. They report that company policies and procedures are followed and on the managers open door policy. They report on the improved supports from the providers regional team during the past twelve months and the use of audit tools to evidence performance. Mrs Gray told us that she worked some shifts, including the odd night duty. She told us that she and a manager from a nearby home would do unannounced night visits, the last one had been in June 2009. Night visits had not been performed by more senior managers from the provider. Mrs Grays recent training had included Deprivation of Liberty Safeguards, person centered care planning and leadership Care Homes for Older People Page 41 of 56 Evidence: matters. During this inspection, we observed that the home continued to have an unmet requirement and some good practice recommendations from previous inspections. Providers and managers need to ensure that when we identify issues which need to be addressed, that they meet them within timescales or up-date us as to the situation and inform us of revised timescales. This has not taken place either in the homes AQAA, the regular reports on the home by a senior manager or by separate letter. Additionally matters were identified at this inspection, which managers should have been aware of, as they have been in the public domain for a period of time. No action had been taken to address the good practice recommendation we made that the results of any quality assurance surveys are given to the people completing the surveys, for example, relatives, which could take the form of a newsletter about the home where improvements are highlighted. We also recommended that an observational tool could be used as many people were unable to comment about the home. The last staff survey took place in 2007. The home is visited regularly by a senior manager from the group and a report on the visit is drawn up. These documented that care plans had been checked and omissions identified. These reports would be more effective if reviews of care plans were carried out in more depth with cross-referencing to other information about the resident. The report showed that generally the senior manager only met with one care assistant each time and in November and October 2009, no care staff were met with at all. As care assistants work closely with residents and as many of the residents in the home have dementia, managers would be likely to gain a clearer impression of how their service provision affects residents if they met with more care staff on each visit. The homes AQAA reported on their infection control audit as evidence of how they provided good outcomes for residents. We looked at the infection control policy and observed that it was general and not specific to the home. For example it did not risk assess the lack of single use hand cleansing and drying facilities in residents rooms, there were no details relating to the laundry facility and ne mention of the management of potentially infected items as we observed during the inspection. The home does have systems for the logging and audit of accidents, including skin flap injuries and unexplained bruising and reddened areas. However we did observe for one resident that while a skin flap injury was noted, the numerous small abrasions on their legs were not. Care Homes for Older People Page 42 of 56 Evidence: We observed that the home looked after some moneys on behalf of residents. There was an audit trail relating to this, with two members of staff signing each entry. We recommended that for security, the safe be fully secured to a load-bearing wall. We also discussed that many homes use a money-less invoicing system for the management of residents moneys. Mrs Gray reported that she had been considering introducing this, as she had observed in a sister home how a cash-less system worked effectively for residents and their supporters. The handyman told us that the check lists normally used had been rearranged during a recent company audit so they were unable to show us some of the regular tests and checks of equipment and service. There was a file with all the receipts for contracted checks of different equipment and services, for example, gas safety checks and maintenance of fire safety equipment. We looked at the training matrix which showed a list of mandatory training for all members of staff to complete, for example, fire safety, infection control and moving and handling. The matrix showed the date of completed training. We considered that while training is taking place, some practice relating to ensuring health and safety needs improvement. For example, we looked as a risk assessment relating to a pregnant catering worker when they were on their own in the kitchen. It stated that they were to be supported by a member of the care staff if they needed assistance when they were on their own. There was nothing in the assessment about how safe catering practice was to be up-held when calling in staff who perform caring duties, such as personal care, to assist in the kitchen. We observed a member of staff roll a dependant resident on their own, to place a slide sheet under them. This needs to be done by two members of staff to ensure the safety of the resident and the member of staff. As noted in Environment above, practice in relation to the management of clinical waste needs improving. There was a lock on one persons bedroom door of the type used on a front door. This meant that members of staff would have to gain entry with the use of a key. Also the person in the room would have to have the use of two hands in order to open the lock and the door handle. Mrs Gray told us that the room was now empty. We said that the home should seek advice from the Fire and Rescue Authority on the suitability of locks so that people who want to lock their bedrooms are not at risk of being locked in their rooms in an emergency. We saw that where people liked to have their bedroom doors open, automatic self closing devices had been fitted. These devices react to the fire alarms going off, closing the door and offering time limited protection until staff can evacuate them in Care Homes for Older People Page 43 of 56 Evidence: the event of a fire. We saw a risk assessment in one persons care plan about the use of their door. Mrs Gray showed us the fire log book. She told us that fire training was completed via E-learning. There was also a talk by the deputy manager who was the fire marshal. We saw that there had been a recent fire drill during the day and one during the evening. Mrs Gray said that people had been evacuated and there was a record of what had occurred during the drill. We did not see any individual fire evacuation plans in peoples care plans. Some records relating to fire safety in residents records were not clear. One persons records documented still at risk in case of fire for her bedroom door for lock and key. The homes fire safety policy had not been filled out with the details of the person responsible and their location. The homes fire risk assessment was dated 1/2/05 with a review date of 31/7/06. There was no evidence that this had been reviewed. Care Homes for Older People Page 44 of 56 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 2 5A The home must provide people with the information required in relation to the breakdown of fees. This will help to make sure that people and their representatives have access to information about the fees charged by the home. 05/01/2009 Care Homes for Older People Page 45 of 56 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Pre-admission assessments must include a full assessment of all of a persons nursing and care needs. This will ensure that the home can meet the persons individual needs. 28/05/2010 2 7 12 Care plans must be put in place whenever a person has a nursing or care need. Care plans must be fully updated when a persons condition changes. Care plans must use precise, measurable language. Care plans are needed to direct staff on actions to take to meet individual need, this ensures that care is delivered in a planned and consistent manner. 28/05/2010 3 9 13 When any medicine is administered to people who live in the home this must 01/05/2010 Care Homes for Older People Page 46 of 56 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 always be accurately, clearly and completely recorded. (This particularly relates to recording the actual dose of medicine administered where a variable dose is prescribed and other shortfalls in the records identified in the report). This is to help to make sure people receive their prescribed medicines correctly and to help reduce risks of mistakes because of poor medicine records. 4 9 13 Put in place safe arrangements, in accordance with best practice guidance, for the handling, storage and recording of any medicines that are applied to the skin. This is to help make sure that people receive these treatments correctly and are not put at risk because of inadequate practices and incomplete records. 5 16 22 The home must provide written evidence that they have fully investigated all complaints. If records are not made of investigations into 28/05/2010 01/05/2010 Care Homes for Older People Page 47 of 56 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 complaints, the home cannot show that it has fully and impartially investigated any complaint. 6 22 23 Equipment must be provided 30/07/2010 to meet the disability needs of residents, including sufficient hoist and equipment to ensure people with a disability can have hair dressing if they wish. This is to ensure that people with a disability have their needs met. 7 22 23 All residents who need to be moved using a fully body sling must be measured for the correct sling for them and provided with their own slings, which are used only for them. This is to prevent risks to manual handling and to prevent risk of cross infection. 8 26 13 All parts of the home, equipment and furnishings must be clean. This is to prevent risk of cross infection. 9 26 13 Practice and equipment in relation to prevention of spread of infection must be improved to ensure that all 28/05/2010 28/05/2010 30/06/2010 Care Homes for Older People Page 48 of 56 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 relevant equipment is provided, that it is intact and fully wipable with all dust and debris reguarly removed, particuarly in laundry and sluice rooms. This is to prevent risk of cross infection. 10 26 13 Single use methods of hand cleansing and drying must be provided in all parts of the home where residents may be given personal care. This is to prevent risk of cross infection. 11 26 13 Systems must be put in place to ensure that underclothes are not used communally. This is to prevent risk of cross infection, as well as to up-hold peoples dignity. 12 29 19 The home must provide evidence of a persons past employment history. This is to ensure that the home can provide evidence of the prospective member of staffs suitablity for their role. 13 29 19 The home must perform a full audit of all its staff files, to ensure that they include 28/05/2010 30/04/2010 28/05/2010 30/06/2010 Care Homes for Older People Page 49 of 56 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 all required pre-employment information for the individual. This is to ensure that the home can provide evidence that they are following safe recruitment practice. 14 30 18 The home must develop a training plan to ensure that increased members of staff undertake training in dementia care and common conditions for the elderly, such as dietary needs, diabetes, stroke and communication needs. This is to ensure that staff can meet residents individual needs. 15 31 37 The home must always inform us of any event which can affect residents well-being. This is to ensure that we are aware of actions taken by the home to ensure residents safety. 16 33 24 The provider must ensure that it meets our requirements and takes action on recommendations or advises us of progress. 28/05/2010 30/04/2010 30/06/2010 Care Homes for Older People Page 50 of 56 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 This is to ensure the health, safety and welfare of residents. 17 37 12 Records of care given must be accurate and completed when nursing and care is provided. All documents must be dated. If records are not accurately completed abd dated, the home cannot evidence that care has been given as needed by the resident. 18 38 13 The homes infection control procedure must be revised and be specific to the home. This is to prevent risk of cross infection. 19 38 13 The homes risk assesment 10/05/2010 in relation to bathing/showering of residents must be fully revised, to reflect directives from bodies such as the Health and Safety Executive. This is to ensure that risks of scalds to residents is prevented. 20 38 23 The home must make sure 28/05/2010 that the most up to date fire risk assessment is made available for inspection. 30/06/2010 14/05/2010 Care Homes for Older People Page 51 of 56 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 This is to ensure that people will be safe in the event of a fire. 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 1 The statement of purpose should have information about how the home cares for people with dementia and those with mental health needs, which should also describe how their privacy and dignity is addressed. The information relating to how to contact us should be up-dated. Parts of this recommendation was identified at the inspection of 6/4/09. It has not been addressed. 2 3 All subsequent assessments after admission should contain sufficient attention to detail to help ensure that peoples dignity is respected. This recommendation was identified at the inspection of 6/4/09. It has not been addressed. 3 4 3 7 Assessments or need or risk should take place in a timely manner, in accordance with research-based guidelines Where a persons first language is not English, care staff should be advised of key words for that person, so that they can explain care being provided and actions taken. Obtain and check the guidance published by the National Patient Safety Agency about Safer lithium therapy and Actions that can make anticoagulant therapy safer. Review the storage arrangements for insulin injections once these have been first used to make sure these are in accordance with the manufacturers directions. Write the date on containers of medicines when they are first opened to use to help with good stock rotation in accordance with the manufacturers or good practice 5 9 6 9 7 9 Care Homes for Older People Page 52 of 56 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 directions and to help with audit checks that the right amount of medicines are in stock. 8 9 Review and update the medicine policy and procedures to include up to date information about all aspects for the management and handling of medicines in this home so that staff have access to good information about the way in which they are expected to handle medicines. Review medicine records and care plans to make sure that any medicines prescribed with a direction when required or with a variable dose have clear, up to date written guidance available to staff that clearly describe how to reach a decision to administer the medicine at a particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure all people living in the home receive the correct amounts of their medicines in a consistent way in line with planned actions. Make arrangements to include an appropriate entry in the allergy section on all medicine administration records as an additional action that can reduce the risk of people being supplied with a medicine to which they are known to be allergic. Residents underclothes should be reguarly reviewed and relatives approached to replace tiems which have deteriorated. The persons preferecne for sex of carer to provide personal care should be documented. Staff should use the residents own name when addressing them and not use generic terms of endearment, without also using the residents name. An audit of plastic cups and place mats should take place and any that are stained or deteriorated be replaced. The people who cook meals should be provided with training on how to meet the dietary needs of people who are frail, have dementia and conditions such as diabetes. Where it is necessary to change the menu choice, information about this should be provided in areas where residents can be made aware. Residents should be given a choice of meal and drinks. 9 9 10 9 11 10 12 13 10 10 14 15 15 15 16 15 17 15 Care Homes for Older People Page 53 of 56 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 18 15 Clothes protectors should be provided individually to residents and only provided when assessed as being needed by a resident. All verbal concerns and the actions taken to resolve them should be recorded. A written reply to relatives about the outcomes of any concerns should be completed. This recommendation was made at the last inspection. It has not been addressed. 19 16 20 19 Improvements should be made to the garden areas of the home, including removal of debris and broken items and planting, to improve views for residents. All of the home, equipment and furnishings should be surveyed and an action plan drawn up to up-grade areas and replace items before they deteriorate further. Staff should check bath/shower water temperatures and maintain a record, prior to bathing/showering a person. Used laundry should be separated at source, not in the laundry The cleaning scedule should be fully revised to make it fit for purpose. The home should consider how it supports and encourages more care staff to undertake National Vocational Qualifications. An observational tool could be used for quality assurance purposes as many people are unable to comment about the home. This recommendation was identified at the inspection of 6/4/09. It has not been addressed. 21 19 22 23 24 25 25 26 26 28 26 33 27 33 Reports on visits to the home by a senior manager should review care plans in more depth and more care staff should be met with on each visit. The results of any quality assurance surveys are given to the people completing the surveys, for example relatives, which could take the form of a newsletter about the home where improvements are highlighted. This recommendation was identified at the inspection of 28 33 Care Homes for Older People Page 54 of 56 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 6/4/09. It has not been addressed. 29 30 31 35 38 38 The homes safe should be secured to a load-bearing wall. The home should consult the Fire and Rescue Authroity about the use of locks on residents room doors. Individual fire evacuation plans should be developed for residents. Care Homes for Older People Page 55 of 56 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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