Inspection on 06/04/09 for Miranda House Nursing Home

This inspection was carried out on 6th April 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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 25/03/10

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 03/06/2010.

Inspecting for better lives 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, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sharon Hayward-Wright     Date: 0 6 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 33 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): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Quality Care (Wiltshire) Ltd care home 68 Number of places (if applicable): Under 65 Over 65 68 68 dementia mental disorder, excluding learning disability or dementia Additional conditions: 10 10 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 building. The fees for this home range from six hundred and thirty pounds to seven hundred and eighty pounds. These fees include where applicable the Funded Nursing Care Care Homes for Older People Page 4 of 33 0 7 1 0 2 0 0 8 Brief description of the care home contribution (FNC). People are able to request copies of the homes Statement of Purpose and Service Users Guide. Care Homes for Older People Page 5 of 33 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: The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The inspection process was started by Sharon Hayward-Wright, however, the unannounced two day inspection and the following report was completed by Kathryn Silvey, regulatory inspector and Mary Collier Commission pharmacist inspector. Fiftytwo people were accommodated and we saw most of them and spoke to a few. We spoke to six relatives visiting the home to obtain their views. The previous inspection was six months ago, therefore we did not send out any further surveys this time. Care Homes for Older People Page 6 of 33 There was direct contact with the homes manager, the deputy manager, Caring Homes operations manager and five members of care and nursing staff. A number of records were looked at including care plans, risk assessments, health and medication records. The care records of three people accommodated were looked at in detail. The environment was inspected and staff were observed engaging with people living in the home. The registered manager returned the Commissions Annual Quality Assurance Assessment, this is a self-assessment about the home and is a legal requirement. What the care home does well: What has improved since the last inspection? The Statement of Purpose had been updated to include the staff qualifications to inform prospective people and their relatives about the experience of the staff employed. We looked at a new improved care planning format recently started for some people, which should make recording and retrieving records easier. The environment has improved with new carpets in the communal areas and some redecoration. The home was free from offensive odours and clean throughout. All double bedrooms are now used as single bedrooms and this practice will continue. The Care Homes for Older People Page 8 of 33 maintenance issues identified at the previous inspection six months ago had been completed. Activities and one to one engagement with people have improved and they include the following; cooking, beauty sessions, a visiting dog, knitting and needlework, nostalgia boxes, use of the Snoozlem sensory quiet room, poetry, gardening indoors, aromatherapy, music and movement, quizzes, story reading, newspaper reading, bingo, games, art themes and sing-a-longs. The manager and nursing staff complete regular supervision of all staff, including the ancillary staff to help ensure that staff have their training needs met and that they are competent. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 33 Care Homes for Older People Page 10 of 33 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 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. The information provided to people and their representatives before they move into the home has improved, however, additional information is required to ensure that everything required is included. People are assessed before they move into the home to help ensure that their needs can be met. Evidence: We looked at the homes Statement of Purpose and Service User Guide, which contained some good clear information about the home, both are given to people before they move into the home. However, there should be 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. Care Homes for Older People Page 12 of 33 Evidence: The Statement of Purpose had been updated to include additional information about the staff qualifications, and the registered managers qualifications and experience. The complaints procedure includes our contact details and the time within which the home will respond. The importance of families providing personal histories for people with dementia could be included, as knowing individual values helps the staff provide person centred care. The Service User Guide had insufficient information about the total fees payable, and about any method of payments, to include nursing contributions, that might subsequently be payable by a primary care trust. This is required by Regulation 5 A (a) & (b). We looked at the homes terms and conditions, which should be included in the Guide to include the arrangements for any additional charges, before a person decides to moves in. We provided the registered manager with information about the provision of fee information by care homes. We looked at the pre-admission assessments completed by the manager for three people, and there was sufficient detailed information to determine that the home can meet peoples needs. We looked at an example of the involvement of a healthcare professional in the pre-admission assessment to help ensure that all needs are known to the home and can be met. The records seen were detailed, signed and dated and a further assessment was completed soon after admission, to include all the activities of daily living, which are reviewed monthly. One assessment for a person admitted in January 2009 stated that spectacles were not worn, however, in the photograph the person was wearing them and relatives told us the spectacles were missing. This inattention to detail does not respect peoples dignity and should be addressed, although it is appreciated that items are sometimes misplaced. We spoke to three visitors about the admission process and they were satisfied with the information and support provided by the staff, however, they were unaware of the last inspection report, which should be made available with the service user guide. Two relatives told us the home had a good reputation locally. Care Homes for Older People Page 13 of 33 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. The care plans are person centred and provide good individual actions for staff to follow and are reviewed monthly. Some minor improvements in recording may help improve the service and ensure that people with dementia have all their needs well met. People are treated with respect, however there may be times when their dignity is compromised. People are protected by the homes procedures for the safe handling of medicines, however consideration must be given to more appropriate, safe storage. Evidence: We looked at three care plans in detail and other records to include medication, and spoke to the people and their relatives. We also asked care staff about how they cared for people. The care plan format for one person included new documentation, which will soon be used for everyone in the home. The records were generally good with clear actions for staff to follow and risk assessments, both were reviewed monthly. There were nutritional, tissue viability, and manual handling risk assessment tools Care Homes for Older People Page 14 of 33 Evidence: used to identify when people may require additional support or advice from a healthcare professional. People are weighed regularly and we looked at a required food record for a person at risk. One person also had a recent cognitive assessment to determine their level of understanding. The care plans clearly identified the outcomes to be achieved and peoples strengths were identified, which was good practice. Any weaknesses identified were risk assessed. We saw a chart in one bedroom where there had been a regular check of the persons position change while they were in bed, and an equipment check to ensure that any pressure relieving equipment was functioning correctly, this is good practice. There were good actions for handling challenging behaviours, to include recording moods. One person was receiving one to one care to monitor behaviours and we observed that staff were engaging well with them. The Community Psychiatric Nurse (CPN) was involved in reviews of the challenging behaviours and protocols for as required medication were recorded. A person recently diagnosed with diabetes had a risk assessment for raised blood sugars and careful monitoring of the levels. The care plan reviews were dated and signed, however, the activity of daily living assessments had more meaningful monthly reviews. The use of waterproof covers on communal chairs has ceased, however, it was unclear if people had been specifically assessed as to how often they should be helped to use the toilet. The manager told us that the staff would generally complete this four hourly, which may not be appropriate for everyone, but no record was kept. There should also be a clear record of when people have a bowel movement as people with dementia are sometimes unable to tell staff they are constipated, which can cause problems. The daily records contained some useful information but to trawl all the records to make certain people have had a bath or shower at least weekly would be difficult, and not best practice for people with dementia. Not all bathing facilities on each floor were appropriate for very frail people. A doctor visits the home weekly and healthcare records include relevant information to include blood test results and a good example was seen. However, one record of a healthcare professional visit was incomplete as the doctor had called and changed medication due to challenging behaviour and this was not recorded there. The persons Care Homes for Older People Page 15 of 33 Evidence: relatives also expressed concern to us about the possible use of medication. This should be discussed with them to help ensure peoples best interests are always taken into consideration when they do not have the capacity to consent. Two relatives of a person admitted recently told us they were unaware of a care plan, however, the manager informed us that they are invited to a review after three months, then quarterly. The manager told us that the care plans are audited quarterly to help identify any omissions. One care plan had a good biography, but the other two did not have one, this could be a problem for staff in helping them get to know what people with dementia value. The manager told us relatives are encouraged to provide a social history. One relative told us they had not been approached, and would have gladly provided additional information. We observed staff speaking respectfully to people and several visitors told us that the staff are very good and that they are impressed with the standard of care provided in the home. A relative told us that the home had ensured that their mother was gaining weight and had plenty of fluids during the day. We saw staff providing people with fluids, which were easily accessible. One relative was concerned with dignity as there was a time when their loved one had another persons clothes on and no footwear. We discussed this with the manager who told us that peoples clothes are usually clearly marked and that sometimes people take their own footwear off unnoticed by the care staff. Adequate supervision should help ensure that this does not happen. We looked at the minutes from a recent staff meeting where staff responsible for individual people (key-workers) had their responsibilities outlined. This included ensuring that people are well groomed and have their clothing and toiletries in good order to help maintain their dignity at all times Our pharmacist inspector looked at medication handling in the home. Medication storage was secure but still very cramped and inappropriately situated. Since the last inspection the correct bolts had been used to secure the controlled drugs cupboard. Medication administration records were clear and refusals were recorded. The guidance and records for an insulin dependent diabetic were particularly noted as clear and useful to staff. All medicines seen that were prescribed as required had clear guidelines as to their use including non verbal indicators for pain relief. These medicines were recorded when they were used, but it would be clearer if the exact time of administration was noted. On the downstairs floor it was noted that some general housekeeping duties had been neglected during the previous week; for example the timely re-ordering of medicines leading to a cream being out of stock. During discussions with staff we discovered that Care Homes for Older People Page 16 of 33 Evidence: the senior nurse had been absent and other staff did not take on responsibility for these duties. Trained nurses administer all the medication and could describe how a medication round should be done safely.They were seen to give medicines appropriately and sensitively, signing the chart when they had seen the person take the medicines. The amount of medication needed for the people upstairs was too much to be safely transported in the lockable trolley available and an extra, unsecured, one was in use. This practice could lead to people in the home or their visitors being able to access medication and so being at risk of harm. Care Homes for Older People Page 17 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has made progress in providing more one to one activities for people and plans to continue with more outings and activities including sensory stimulation. The home provides a varied menu and people enjoy their meals in an unhurried atmosphere. Evidence: We observed staff completing one to one activities with people in armchairs and sitting round a table in a group, puzzles and games were being enjoyed with the staff and a group were using a balloon between them. One person was holding a doll and appeared relaxed and content being with other people. An atmosphere of quiet activity and staff engaging meaningfully was seen. We spoke to a member of staff involved with activities and care, who is completing a person-centred dementia care course with the registered manager. The carer was able to explain what she had learnt, which was being passed to other care staff to improve peoples activity and care. An observational tool had been completed as part of the training, which had helped the staff identify where improvements could be made. Care Homes for Older People Page 18 of 33 Evidence: There are plans to provide more sensory materials such as silks to feel and pomanders to smell. We spoke to enthusiastic staff who had used some of their own time to turn an office into a quiet room for activities and for visitors to entertain their relatives, and prepare hot drinks or food for them in a small kitchen attached. We looked at the four weekly activity plan which included; cooking, beauty sessions, a dog visiting, knitting and needlework, nostalgia boxes, use of the Snoozlen for sensory activity, poetry, gardening indoors, aromatherapy, music and movement, quizzes, story reading, newspaper reading, bingo, games, art themes and sing-a-longs. There were areas of interest for people to interact with in the home, for example, lots of different hats and accessories to wear and a mannequin dressed up that people could touch, another area had an ironing board and a washing line and basket where clothes could be folded and pegged out. The Snoozlen room was attractive and staff bring people there to sit quietly, listening to the music and interact with the sensory equipment. The manager told us that several people enjoy using it, however, the relatives spoken to were unaware there was such a room. In the conservatory there were plants growing in pots as some people enjoy gardening. The manager has plans to improve the garden with raised flower beds for ease of access. The home completes fund raising to help with the activity budget enabling people to be taken out to the town centre, to local lakes, the theatre and pantomime when staff are available. Relatives are invited to meetings and are asked for help with social histories. We looked at some bedrooms that were personalised and attractive, others looked less welcoming and people should be able to choose additional pictures etc. to improve their rooms. One relative was concerned that people spend too much time alone in their own rooms, this was discussed with the manager who told us that some people are very reluctant to join a group and staff allow them to be alone and eat in their rooms if they wish. It is good practice that people are able to access their own rooms and be surrounded with familiar items when they wish, and that they are able to move freely about the home when able. We observed people being able to wander where they wanted to and engaging with staff and relatives. There are small activity lounges where relatives and friends can relax in private. The AQAA told us that in the last twelve months improvements have been made with more visits to the home by volunteers, animals visit the home to provide more stimulus and there has been more involvement within the local community. The home has a monthly church service for all people to join in with, and the Catholic church nearby can meet spiritual needs when required. New activity rooms have been provided on both floors. Care Homes for Older People Page 19 of 33 Evidence: The home could produce a newsletter to inform people and their relatives of improvements and events taking place. We observed people during mealtimes and staff were sensitively helping people with their food and they all appeared to enjoy the food they were eating. We looked at the choices people have on the menu and a record in the kitchen of what people ate each day, we also spoke to the manager about special diabetic and soft diets and appropriate food is provided. The home has two chefs and a few people living in the home were able to tell us that they had enjoyed their lunch. We also observed supper where people were enjoying a variety of food and fresh fruit. The visitors told us the food was very good and one relative was very pleased that her mother had put on weight and was enjoying her food again. We saw care staff helping people with their meals in a sensitive and unhurried manner. There was a variety of drinks available for people to choose from. The AQAA told us that seventyfive percentage of the catering staff and a twentyfour percentage of care staff have basic food hygiene training. The care staff told us that when people dont eat their meals it is recorded and a risk assessment, to include the use of a food chart, may be used. People are weighed regularly and a record is kept to help identify people at risk of malnutrition. Care Homes for Older People Page 20 of 33 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure had been updated in the Service User Guide, and relatives know whom to complain to. Verbal concerns are not dealt with formally, however, records should be kept. Staff are well trained to help ensure people are safeguarded and that the homes procedures are followed. Evidence: We looked at the complaints procedure and we have commented on this in standard one of this report. The complaints procedure on the wall in the entrance hall should be more clear. The manager told us there had not been any complaints since the last inspection six months ago, but there was a safeguarding issue involving challenging behaviour. We looked at the records and the consultant psychiatrist had been involved to help monitor the persons condition and to provide guidance and support to the staff. We looked at the updated procedure relating to managing challenging behaviours, and we spoke to staff that knew what to do in challenging situations. We observed care staff providing one to one support for one person. Twelve staff had received training in break-away techniques in April 2009 to help recognise and diffuse challenging behaviours. Caring Homes, the provider, complete most of the Safeguarding training for staff, and we looked at the training matrix that identified who had been trained. There are Care Homes for Older People Page 21 of 33 Evidence: approximately seventy staff including ancillary staff and the homes own bank staff, and all but one had completed Protection of Vulnerable Adults training within the last twelve months. This is good practice and helps to ensure that people are well protected. We spoke to staff and they knew about protecting vulnerable adults and alerting someone, whistle blowing, should any type of abuse be suspected. The home had a safeguarding procedure which included whistle blowing, the procedure was last reviewed in December 2007. The visitors we spoke to felt able to complain to the manager should they have any concerns, however, relatives of a person recently admitted had voiced concerns but felt nothing was happening. We spoke to the manager who agreed to look into the concern that items had gone missing, subsequently the items were found. It is important that verbal concerns and the action taken to resolve them are recorded. A written reply to relatives about the outcome of an issue should be completed. Care Homes for Older People Page 22 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had improved the standard of the environment and it is well maintained, clean and free from offensive odours. Minor improvements would ensure infection control arrangements protect people at all times. Evidence: We looked at all the communal rooms, several bedrooms, bathing facilities, the laundry and the kitchen. The manager told us that all rooms are now used as single bedrooms and there are no plans for people to share a room in the future. The home was free from offensive odours and all areas seen looked clean, relatives told us the home was usually clean. All the issues identified at the last inspection as requiring action had been addressed and the home was well maintained and decoration was ongoing for the bedrooms. There were new carpets in the entrance hall and corridors. The manager told us that there are plans to provide picture emblems on doors to alert people to where they are and where toilet facilities are. The environment could be improved in line with the latest dementia care practice, particularly with the use of different colour schemes. The manager and a carer were currently updating their knowledge to help ensure the home promotes good dementia care practice. Some Care Homes for Older People Page 23 of 33 Evidence: bedrooms in the home had bare walls and we have mentioned this in standard 12 of this report. The upstairs lounge was too warm on a cool day and staff told us in the summer it is difficult to keep this room cool enough for the comfort of the people living there. The manager should ensure that people who may be unable to tell staff they are too hot have the room temperature monitored and air conditioning provided if necessary. There were insufficient handwashing facilities for staff in the communal bathrooms to promote infection control. The manager should ensure that there are adequate bathing facilities for frail people to have a choice of a bath or a shower on each floor. The home and gardens were secure to help safeguard people and the manager had plans to improve the garden area to make it more interesting for people to enjoy. The experienced laundry staff told us how infection control is managed, however, there should be a procedure for staff to follow to ensure that everyones knows about infection control practice there. Staff were wearing protective clothing, and the AQAA told us that fifteen staff have completed infection control training, and the home has a policy and procedure for staff to follow, including the Department of Health Guide Essential Steps. We looked in the homes maintenance book and tasks requiring attention were logged and all had been completed. It would be useful if dates were recorded to help ensure that health and safety matters are addressed quickly. Care Homes for Older People Page 24 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has sufficient staff to meet the needs of the people accommodated and provides access to relevant training to help ensure they have the correct skills and people are safe. The recruitment records could be improved to help ensure that people are safeguarded Evidence: There is a weekly staffing review where peoples dependency needs are identified together with the weekly clinical governance model, which reviews accidents, the prevention of pressure ulcers, incidents and falls. The relationship between the reviews help the manager ensure there are sufficient staff on duty to meet peoples needs. A monthly collation of accidents also helps to look at trends, and is another check that sufficient staff are available to safeguard people. The staff told us there was usually sufficient staff available to meet peoples needs and three staff told us they like working in the home. We observed that there were sufficient staff to help people at meal times and people were well supervised in the communal rooms with many meaningful activities. Only three shifts have used agency staff in the last month. We looked at the staff training matrix, and the following training had been completed by most of the staff, including the ancillary staff and bank staff; manual handling, first Care Homes for Older People Page 25 of 33 Evidence: aid, health and safety, fire safety and fire drill practice. In addition to the mandatory training staff had completed infection control, dementia awareness, end of life care, stoma care, pressure area care, Control of Substances Hazardous to Health (COSHH) and reporting/record keeping. The chef completed a catering development day in 2008. The manager told us that fourteen people will be completing equality and diversity training soon and that the three activity co-ordinators will be completing specific activity training in May 2009. The new staff recruited in the last three years had completed the Skills for Care induction programme. Registered nurses complete medication administration in the home and six of the nine nurses, which included three bank nurses, had completed medication training in August 2007 and we recommend that all trained nurses complete medication update training annually. Two registered nurses had completed a diabetes course in 2008, and one a wound management course in 2007. The manager had completed a dementia awareness course in 2007 and is currently completing a leadership dementia care course. We recommend that all nurses complete a dementia awareness course. The manager told us that the provider is planning a dementia care course for all staff. We looked at a Dignity Audit that staff complete to help the manager identify that all staff understand what dignity is and how the home ensure people are treated with dignity. The staff told us they were well trained and had regular supervison, they also told us the training included dementia care and end of life care. The home has regular staff meetings and we looked at the minutes of one meeting. The AQAA told us that of the thirtyseven care staff twelve have the NVQ level 2 in care qualification and six are working toward it. We looked at two new recruitment records and all the relevant information was recorded including interview notes. When staffs last employer is overseas there should be a reference from the address, this was not the case in one record and the manager was advised to obtain a further reference from overseas. When English is not a member of staffs first language the manager completes the second interview to help ensure that staff can adequately communicate with people, subsequently some staff have completed English courses. Care Homes for Older People Page 26 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed by a competent manager and the outcomes, to help ensure safe working practices and the completion of adequate staff supervison, have improved for people. Evidence: The registered manager is a Registered Mental Health Nurse with twentyfive years experience and has completed the Registered Managers Award. We looked at how the home manages peoples personal monies and there was a good system and all monies were correct. The manager and nursing staff complete supervison of all staff, including the ancillary staff and an example was seen. Staff told us they were regularly supervised and that they found it helpful with regard to training needs. We looked at two regulation 26 visits completed by the operations manager about the service. A good format was Care Homes for Older People Page 27 of 33 Evidence: used and there was sufficient information and actions identified, when required, to help ensure that improvements were made. The AQAA told us that polices and procedures had been reviewed in December 2007. We looked at the new format for infection control, there was a policy and procedure on both floors. Quality assurance methods include the use of questionnaires to people living in the home and their relatives and internal staff audits. One carer had recently learnt how to complete an observational tool, which could be used for quality assurance purposes as many people are unable to comment about the home. We recommend that the results of any quality assurance surveys are given to the people completing the surveys, which could take the form of a newsletter about the home where improvements are highlighted. The AQAA told us the homes equipment is serviced or checked in accordance with the manufacturers recommendations. The training matrix indicated that most of the staff have had health and safety training and the manager told us that fire risk assessments are complete and many staff had recently completed fire drill training. The manager told us that fourteen people will be completing equality and diversity training soon. Care Homes for Older People Page 28 of 33 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 29 of 33 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 1 5 The registered person must provide a copy of the most recent inspection report and the homes standard form of contract for the provision of services and facilities. This will help to provide people and their representatives with information about the services offered by the home. 15/05/2009 2 2 5A The registered person must 15/05/2009 provide information about the service and fees payable in respect of the services provided and the method of payment of the fees and the persons or person by whom fees are payable. This will help provide people and their representatives with the fee information about the service offered and by whom it is payable. Care Homes for Older People Page 30 of 33 3 8 13 The method of administration of medicines to people on the upper floor must be risk assessed and a suitable, safe procedure adopted. This will ensure that people are not at risk from unsecured medicines. All trained staff must take responsibility for ensuring that medicines are available and managed appropriately at all times. This will ensure that staff absences do not affect the safe management of medication. 22/05/2009 4 8 13 22/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 We recommend that 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. We recommend that all subsequent assessments after admission contain sufficient attention to detail to help ensure that peoples dignity is respected. We recommend that relatives should be informed about any changes for people with dementia as they would be involved in their best interest decisions where appropriate. We recommend 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 recommend that there should be an individual timing in 2 3 3 7 4 7 5 7 Care Homes for Older People Page 31 of 33 the care plan for assisting people to the toilet, as this may vary, to help encourage continence and promote dignity. 6 7 We recommend that biographies are obtained from relatives as soon as possible to help staff identify peoples values. Medicines prescribed as required should be recorded with the exact time of administration so that a clear record of administration is maintained. We recommend that all verbal concerns and the actions taken to resolve them are recorded. A written reply to relatives about the outcomes of any concerns should be completed. We recommend that there are sufficient handwashing facilities for staff in the communal bathrooms to promote infection control. We recommend that the registered person ensures that people who may be unable to tell staff they are too hot have the room temperature monitored, and that air conditioning is provided when necessary. We recommend that the registered person should ensure that there are adeqaute bathing facilites for frail people to have a choice of a bath or a shower on each floor. We recommend that people in bedrooms with bare walls have a choice of accessories to improve their environment. We recommend that there is an infection control procedure in the laundry for staff to follow to help ensure that all staff know about infection control practice there. We recommend 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 recommend that an observational tool could be used for quality assurance purposes as many people are unable to comment about the home. 7 9 8 16 9 19 10 19 11 19 12 13 19 26 14 33 15 33 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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