Inspection on 02/11/09 for Montague House

This inspection was carried out on 2nd November 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Montague House 19/03/09

Montague House 15/04/08

Montague House 25/04/07

Montague House 28/11/06

Montague House 08/05/06

Montague House 17/10/05

Montague House 11/05/05

Montague House 19/01/05

Montague House 11/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: Montague House Montague House 10 Brockenhurst Road Ramsgate Kent CT11 8ED     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: Christine Grafton     Date: 0 2 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Montague House Montague House 10 Brockenhurst Road Ramsgate Kent CT11 8ED 01843591907 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Roy Edward Howse care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 19 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Montague House is a detached two-storey building with 19 bedrooms. 18 bedrooms have ensuite facilities of a toilet and washbasin; all rooms have a call bell and television point. There is a stair lift to the first floor. There is a large garden to the front and rear of the building, providing a number of areas for residents to sit, with an off-street parking area to the front. The home is located in a quiet residential area of the town, close to the cliff top promenade. The nearest shops and amenities in the town centre are within easy reach. Montague House admits people with low to medium dependencies and does not accept people who are wheelchair dependent for Care Homes for Older People Page 4 of 38 Over 65 19 0 1 9 0 3 2 0 0 9 Brief description of the care home mobilisation and cannot stand without lifting equipment to move them. The home does accept people who use aids such as walking sticks and walking frames. The staff team work a rota that includes one person on waking duty and one person on duty sleeping in at night. Information provided by the manager in November 2009 indicates that the fees range between £328:65 to £520:00 per week and additional charges are made for hairdressing, chiropody and newspapers. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This report takes account of information received since the last inspection of 19th March 2009, including a visit to the home. We visited the home on 2nd November 2009 without telling anyone we were coming so that we could see what it is like for people living there on a usual day. We arrived at 09.25 hours and left the home at 16.45 hours. We spoke to the manager, staff and residents. The manager showed us around the communal areas of the home and we saw a sample of bedrooms. We observed what was going on, the home routines, staff practices, and if any activities were taking place. We looked at some of the homes records and saw the lunchtime meal being served. We also used the homes annual quality assurance assessment known as an AQAA for short. This is a document that all homes have to send us once a year to tell us how they think they are meeting the national standards, how they have improved in the Care Homes for Older People Page 6 of 38 previous year, what they aim to do and lets us know when they have completed important environmental safety checks. Information from the last inspection is also referred to. We sent some surveys out to a sample of residents and staff prior to our visit. Their responses have been used to inform our judgements and will be referred to in the report. We also looked at relevant information we have received from other organizations. This includes the findings and outcome of a recent visit by the local authority contracts officers, which will be referred to throughout this report. At the time of our visit there were 14 residents living at the home. The people who live in the home prefer to be called residents and this is the word used to describe them throughout the report. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? The manager has worked hard to develop residents care plans so that they contain more personal information about each individual. Care plans now contain detailed guidance for staff that cover all aspects of each persons health, personal and social care needs. The care staff have improved the way they write residents daily records that are now more descriptive and show more clearly how the resident has spent their day, with indications of mood and well being. Risk assessments have been developed for each resident and they now contain clear guidance on actions to be taken to reduce risk. However, in one instance a care plan did not show the follow up action after a residents falls. (See below under What They Could Do Better). The staff rotas are much clearer than those seen at our last inspection and show that staffing numbers and roles are being more carefully planned. A staff training matrix has been devised that shows the mandatory courses to ensure residents health and safety. This indicates that in the last three months two staff have updated their first aid training and three staff have recently updated their fire training. Care Homes for Older People Page 8 of 38 The manager now needs to ensure that all other courses are added to the matrix too, as evidence of good practice. Staff have continued to attend various short training courses to develop their knowledge and skills. This should therefore give residents confidence that staff know how to meet their needs. The management have started to carry out a range of monthly quality monitoring audits. This provides a means to identify anything that needs addressing so that any necessary changes can be made for the benefit of the residents. What they could do better: As a result of the recent visit by the local authority contracts officers, some shortfalls were identified that the management have responded to and they have started to make changes for the benefit of the residents. However, they still have a number of things to do to safeguard and fully protect residents. They now need to make sure that the home is proactively and effectively run in a way that promotes and safeguards residents best interests. They have a document that they show prospective residents to give them an idea of what to expect should they decide to move into the home. They need to separate the information into two separate documents, one specifically for residents, which is known as the service users guide. This should have the practical things in it to help them learn about the home. They also need to make sure that both this and the fuller document, called the statement of purpose, are reviewed and updated as things change. The manager must be vigilant in recording pre admission assessments for all prospective residents and to confirm in writing that the home can meet the persons needs. This is to make sure that the needs of all new residents can be properly met upon moving in. Care plans now need to be regularly reviewed each month and updated to address any changing needs. This is so that staff have all the information they need to ensure that residents receive the right care to keep them safe. They must make sure that they properly record in the care plan actions taken following a residents falls. This is so that staff have a clear picture of what has happened, the reasons why and what they should do in future to reduce the risk of further accidents occurring. The manager needs to make sure that residents are offered a range of stimulating activities to occupy their time throughout the whole week. This might mean adjusting staffing levels to allow enough staff time available to organize activities when the activities person is off duty. This is so that all residents can lead fulfilling lives. The manager needs to make sure that staff know what constitutes a complaint and that any complaints received are recorded in the homes complaints records, with details of the investigation and outcome. Care Homes for Older People Page 9 of 38 Arrangements need to be made for the manager and staff to receive the necessary training to do their jobs effectively and safely. The manager needs to arrange training on the Mental Capacity Act and Deprivation of Liberty Safeguards for herself as soon as possible and then to arrange this training for the care staff to receive during the next twelve months. This is important as this is relatively new and the manager should know all about it and what is required by the home and staff to protect the residents. Arrangements also need to be made for those care staff that have not yet completed their mandatory training on the protection of vulnerable adults to do so without any unnecessary delay. The flooring in the ground floor bathroom needs replacing, as it is open at the seam and is not impervious. This is important to maintain hygienic and reduce the risk of spread of infection. The manager must make sure that there are enough staff on duty at all times so that the needs of all the residents living in the home are met and cleanliness and hygiene are maintained. This includes making sure that there are enough staff on duty throughout the whole week to provide care to residents, plus additional staff to do the cleaning and cooking. This needs to be done soon and we have set a six week time frame from the date of our visit to ensure the safety of the residents. They also need to keep their night staffing levels under review. The homes recruitment practices need strengthening to fully protect residents. The manager must make sure that anyone employed to work at the home has undergone a number of security checks to see if they are trustworthy to be with the residents. In order to show that they have done this, they must keep all the necessary information in the staff files, including two written references. The staff training programme needs to be developed to make sure that staff update their knowledge and skills in all the mandatory areas. The providers monthly visits need expanding to include interviewing of a sample of residents, their representatives and staff. The visit reports then need to be kept available for the manager to refer to, and for us to see upon request. This is to show that they are monitoring the standards in the home and trying to make sure it is being run in residents best interests. They must make sure that they report any accidents, injuries or other serious incidents to us and confirm this in writing. They also need to make sure that the causes of any accidents are investigated and especially where falls are involved, these are analysed so that any remedial action can be taken. 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 Care Homes for Older People Page 10 of 38 order line 0870 240 7535. Care Homes for Older People Page 11 of 38 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 12 of 38 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 considering moving into the home benefit from being shown written information about it to help them choose whether to move in. However, some of the information is not up to date. The lack of a separate service users guide means that they do not have all the information needed to be fully informed about what to expect if they move in. The assessment process for the new person has improved so that staff now have more information to enable them to provide the right care to them. However there are still some inconsistencies in the way that the pre admission assessments are done, so that prospective residents cannot always be confident that the home can meet their needs. It is not the general policy of the home to admit residents for specialist intermediate care, so standard 6 was judged as not applicable at this inspection visit. Care Homes for Older People Page 13 of 38 Evidence: People considering moving into the home are given the opportunity to read the homes statement of purpose when the manager goes out to assess them, or if they visit the home. This tells them most things about it and covers the homes aims, objectives, services and facilities, fees and charges. They have incorporated some of the things that should be included within the service users guide and have a combined document. This had been reviewed in April 2009 but the manager had not kept up to date with changes to the commission office address that have occurred since then. The document therefore needs to be amended so that people know how to contact us if they wish. The manager says she photocopies relevant parts of the statement of purpose to give to new residents. However, it does not include much about the home routines and what to expect upon moving in. The manager says she will develop a separate service users guide to give to all new residents, to include practical day to day things like, mealtimes, food choices, when the hairdresser visits and how they get a newspaper delivered if they wish. We talked to the manager about the pre admission assessment process for two people and looked at their records. The homes assessment documentation for one recently admitted resident contained lots of detail about their needs, covering the activities of daily living such as, personal care, continence, mobility (including risk of falls), nutritional needs and a dependency assessment. A copy of the care management assessment had also been obtained before the person moved in and this has further information. A detailed care plan had then been drawn up following admission. This was well ordered with separate care plans for washing, dressing and personal care, eating and nutrition, health and medication, activities, religion and beliefs, mobility and there was a falls risk assessment. The procedure for the second person had involved them visiting the home when the manager said she carried out her own assessment. However this had not been documented, although a copy of the care management assessment had been obtained, which contained up to date information about their needs. The manager stated she feels the home can meet this persons needs, but the home has no written evidence to support this. Also they have not written a letter to the person confirming that the home can meet their needs. Overall we saw that they have made significant improvements to the assessment and care planning process. However, the evidence above and a recent visit by the local authoritys Contracts Officer indicated that the pre admission assessment process had not been robust enough to ensure that prospective residents expectations and needs Care Homes for Older People Page 14 of 38 Evidence: can be fully met. Therefore they need to take further action to obtain and record enough information in the pre admission assessment, so that the needs of all new residents can be comprehensively met upon moving in. Care Homes for Older People Page 15 of 38 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 benefit from having a plan of care that has recently been developed to provide staff with the information needed to make sure that their health and personal care needs can be met. However, residents cannot be sure that any new risks will be promptly identified and acted upon straight away so that all risks are minimised. Residents are protected by the homes policies and procedures for dealing with medicines. The staff team have developed a good understanding of residents needs and treat them with respect for their privacy and dignity. Evidence: At the last inspection, care plans provided only basic details and did not contain enough information to enable staff to provide the right care. Therefore, we made a requirement for care plans to set out in detail the action to be taken by staff to ensure that all aspects of their health, personal and social care needs are met. At this visit, we saw that improvements have been made and the requirement has been met. Each resident has a plan of care that now contains most of the information necessary to provide them with the appropriate care. Care Homes for Older People Page 16 of 38 Evidence: We had a thorough look at three care plans and also briefly looked at one other. They say in their AQAA that the care plans give much clearer information on the resident and clearly state what care is required throughout the day and night, with instructions for staff on how this is to be done. We found that this is correct. There is lots of relevant information covering a range of needs. For example, a plan for personal care gives detailed instructions on how to help with washing and dressing, emphasizing about choice of clothing, hair care, denture care, nail care, how to assist with toileting to maintain dignity, changing continence aids and reminding about infection control precautions. Care plans cover other things like skin integrity and risk of breakdown; nutrition and any help needed with eating and drinking; mobility, any aids used and assistance needed; and risk of falls and falls prevention. At our last inspection, risks were not being properly recorded and followed through within the care plans and we made a requirement that care plans must contain clear guidance on actions to be taken by staff to reduce risk. We saw evidence that the requirement has been met in that each care plan now contains detailed risk assessments. However, no follow up action had been taken to carry out a falls investigation where a resident had fallen and sustained injuries five times in a two month period. Although medical attention had been appropriately sought and given at the times, management had not analysed the falls, looked for any trends, or taken action to reduce the risk of further falls happening again. There was no evidence in the care plans of regular reviewing and the environmental risk assessment had not been reviewed or updated. This was despite some of the falls having occurred at night in the persons bedroom, when one record states the person had bumped their head on something and sustained an injury. Subsequently following advice from a district nurse, the bedside cabinet had been moved away from the bedside, but this was one month after the event. This had been identified in a recent visit by the local authoritys contracts officer, following which management had taken prompt action. The persons care plan had been reviewed, night checks had been increased to half hourly and during our visit, staff were making sure that residents sitting in the lounge area were being supervised. However, this might not be possible during weekend afternoons and evenings when there are only two carers on duty (see Staffing Section). The quality of the daily records is another area that was highlighted at the last inspection as needing to be more descriptive and detailed. Again we saw that Care Homes for Older People Page 17 of 38 Evidence: improvements have been made and the daily records are now starting to show how residents have spent their time, with details of things like activities, meals, mood, bedtimes and visitors. We saw details of contacts with doctors and district nurses and an entry that a resident had received communion. We spoke with three residents who said that the staff are kind and caring, giving them the assistance they need. We spoke to two care staff members and it was clear that they have a good understanding of residents needs. There continues to be a stable staff team and residents spoken to were appreciative of this. Three residents returned their service user surveys and they all answered Always that they get the medical care they need. One survey included a comment, I get looked after very nicely. We looked at the way medications are managed and saw that things are in order. Medication storage is safe and they have good procedures in place. We saw that medication administration records (MAR sheets) were all well completed. Staff that administer the medicines have completed medication training. Since our last inspection the manager has carried out regular medication audits and started staff competency assessments. Records state that the person observed carried out the procedure competently, but do not show how this judgement has been made. The manager now needs to develop these records to provide more robust evidence. Staff were seen interacting with residents in a friendly and respectful way. This was confirmed in the three surveys we have received from residents. Records and observations confirm that dignity is respected. Continence aids are now being discreetly stored. We made a recommendation in our last report to make sure that telephone conversations about residents are not overheard. This related to the telephone in the dining room being used by staff to call doctors to discuss residents health. The manager stated that a new telephone with mobile handset had been purchased recently but was faulty and has to be returned. In the meantime, the managers office is used when she is on duty and the room is unlocked, otherwise staff try to be as discreet as possible when using the phone. The manager made an assurance that another telephone with a mobile handset will be obtained. This will then ensure that confidentiality is maintained. Care Homes for Older People Page 18 of 38 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 benefit from being provided with some opportunities to take part in activities to interest and stimulate them. They are encouraged to keep in contact with families and friends and enjoy their food and the choices available to them. Evidence: At our last inspection we made a recommendation to develop more person centred care plans that show how equality and diversity issues are addressed. Since then, the home has been working with the local authority contracts officers, who have carried out three contracts visits. The manager confirmed that the home has responded to our recommendation and those made by the contracts officers to improve the care plans and that they are trying to make them more centred around each person as an individual. Care plans are now starting to show some details about residents expectations and preferences, their social, cultural and religious wishes and how these are being met. Care plans show that two residents religious needs are being met and we saw evidence in the daily records of contacts with families and other visitors. Care Homes for Older People Page 19 of 38 Evidence: The manager has identified in the AQAA that social activities are an area where they could do better. The AQAA states that they have a lady who attends 10 hours a week to provide activities and that the person spends one to one time with residents, such as a private chat, a game of dominoes, or help with a crossword. On the day of our visit this person was on duty, but covering for the cleaner, so there were no activities taking place. We spent time in the lounge where there were eight residents sitting with the television (TV) on. Two residents were occupying themselves by reading, whilst the others were either sitting with their eyes closed, or watching TV. Activities listed on notice board, include bingo, board games, a fortnightly film show and a visit by a monthly musical entertainer. We saw evidence in the daily records of a residents enjoyment from joining in with the bingo. One person indicated in their survey that the home always arranges activities that they can take part in if they want and two answered usually. The three residents that we spoke with said that they find their own things to occupy their time. One spoke of their enjoyment from sitting in the garden in the summer months. However, there is still not a lot going on for residents to occupy themselves if they are not able to pursue their own interests without assistance. Also staffing levels (see Staffing Section) are not always adequate to allow enough staff time available to organize activities when the activities person is off duty. We observed the lunchtime meal being served to residents. This was being done in a calm unhurried way. Where residents needed help with eating, staff were seen calmly assisting them and encouraging them to feed themselves if able. We talked to the cook who said that choice is offered at every mealtime. She goes round each morning to ask what the residents would like for dinner and the care staff go round in the afternoon to check about the tea time choice. They have a four week menu plan that shows a varied nutritious diet that includes home made meat pies and puddings. The cook has a level 2 Food Safety in Catering certificate and has also completed a three month course on nutrition, where she learnt about cultural food choices, healthy eating and how to plan a healthy diet that she said was very enlightening. Feedback from residents in the three surveys received indicates that two usually like their meals and one sometimes does. The residents that we spoke to said that the food is good and they confirmed that they enjoy the choices available to them. Care Homes for Older People Page 20 of 38 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. Residents can be confident that if they have any concerns they will be listened to and acted upon. However, management and staff lack recognition about the importance of recording concerns and follow up action. The homes procedures and practices to safeguard residents from harm need to be strengthened. The record keeping has not been robust enough to make sure that residents are properly protected. Evidence: We spoke to three residents who said that staff listen to them if they need to talk about anything that might be troubling them. They also commented that the manager is approachable and they are confident that she would sort out any concerns. Of the three service user surveys returned, two indicated that staff always listen to them and one that staff usually do. All three answered that they know how to make a formal complaint. Two staff returned their surveys and indicated that they know what to do if someone has a concern. We also spoke to two staff members about this during our visit and they confirmed this and had a good understanding of adult protection procedures. The AQAA indicates that they have not had any complaints in the last twelve months. The manager confirmed this and said that they do not usually have any, but deal with any minor concerns and issues on a daily basis and have had nothing that has got to Care Homes for Older People Page 21 of 38 Evidence: the formal complaint stage. However, on further discussion it transpired that there was a complaint that had been dealt with and recorded in a residents care plan. This shows that the outcome had been recorded and discussed with the complainant who had been satisfied. This should have been recorded within the homes complaints and concerns records. The staff training matrix indicates that three staff have completed adult protection training since our last inspection. This means that half of the staff team have now completed this training. There are still three carers that have not completed this yet and this is still to be addressed. None of the staff have done any training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). The manager has obtained copies of the Department of Health Guides on this, which are displayed by the visitors book. The manager said she knows about the changes but that they have no one at the moment that has needed a DOLS assessment. She indicated she would try to book training on this as soon as possible. We discussed that the manager needs to do this training without delay and then this should be included within their development plan for all care staff to do over the next twelve months. The findings during the recent local authority contracts visit, where a lack of action to reduce risk following a residents falls was identified indicate that procedures needed tightening to fully protect residents. The management have taken prompt action since and have introduced safety measures. However, although the delay had not resulted in an adverse outcome in this instance, this is only because of the contracts visit. Care Homes for Older People Page 22 of 38 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a comfortable, homely environment that suits their individual and collective needs. Practices to maintain hygiene and prevent the spread of infection in the home have been strengthened to protect residents and staff. However, the manager has not consistently been proactive in this area, but she has recently started to be more vigilant in her monitoring of cleanliness and hygiene in the home. Evidence: We looked at the communal areas of the home and a sample of bedrooms. The majority of the areas seen were clean and fresh smelling. The AQAA states that the cleaner has been working through a programme to clean all carpets in the home and we saw that the majority were clean. The manager stated that they are having new carpet fitted in the inner hallway later during the week of our visit. The dining room carpet is still worn in one area from chairs being moved up to the table. This will need replacing at some point. The lounge is comfortably furnished and the bedrooms that we saw on this occasion have been personalized and suitably furnished. Toilets are fitted with raised seats and toilet surrounds where necessary. The flooring in the ground floor bathroom still needs replacing, as it is open at the seam and is not impervious. This was highlighted at our Care Homes for Older People Page 23 of 38 Evidence: last inspection and the manager said that she thinks the provider has this planned to do next. The laundry was seen to be clean and tidy. It is suitably equipped with a washing machine and tumble drier. A red alginate bag system is used for soiled items. They have a system for separating laundry items for high and low temperature washes and they wash soiled laundry separately at a higher temperature first, before it goes into the main wash. There is a double sink and separate hand basin, with liquid soap and paper towels. Hazardous liquids are kept in a locked cupboard. At the recent visit by the local authority contracts officer, the home was not very clean. The weekend cleaner had left and the manager had done nothing about covering, which meant that with only two carers and a cook on duty at the weekend, the cleaning had not been done. The manager has since taken action to make sure that the cleaning duties are covered at weekends. This was apparent as our visit was on a Monday and most areas of the home that we saw were clean. The manager has taken action to make sure that staff follow the correct procedures to prevent the spread of infection in the home. This has included providing liquid soap, paper towels and hand gels throughout the home. The manager needs to make sure that there is a system for these to be regularly checked and kept topped up. Care Homes for Older People Page 24 of 38 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 benefit from the stable staff team that know them well and understand their needs. However they cannot be confident that there will be enough staff on duty at all times to meet their assessed needs. This includes having enough cleaning staff on duty throughout the whole week to maintain cleanliness and hygiene and protect them from the spread of infection. The recruitment practices need strengthening to fully protect residents. The staff training programme needs to be developed to make sure that staff update their knowledge and skills in all the mandatory areas. Evidence: They continue to have a stable staff team. The three residents that we spoke with were appreciative of this. Answers in two of the three service user surveys returned indicated that there is always enough staff available when they need them and one that there usually is. We looked at the staff rota and discussed staffing levels with the manager. These were much clearer than those seen at our last inspection. The rota shows three carers on duty weekday mornings, plus a cook. A cleaner is rostered to work during the week and there is a weekend cleaner vacancy. During the afternoons and evenings there are two carers, plus the manager covers the teatime shift during the week. Care Homes for Older People Page 25 of 38 Evidence: At the recent visit by the local authority contracts officer, at weekends there was no cleaner and only two carers on duty, plus a cook in the mornings. This means that not only did the cleaning not get done, but that care staff also had to prepare the evening meal. Whilst this was being done, it left only one carer to supervise residents in the lounge. If that carer then needed to attend to someone in another part of the building it left no one to supervise the lounge area. As there are some residents at risk of falling, this means that they were not being adequately protected. The manager has subsequently acted to cover the weekend cleaning shifts by putting an additional carer on shift, or by the weekday cleaner doing an extra shift. The rota has been structured so that the extra carer does the afternoon and evening shift, also covering the evening meal time. At our last inspection we had discussed that weekend staffing levels needed to be kept under review. The manager stated that they have just started to advertise for another carer to cover the weekend afternoon and evening shifts. This had only come about as a response to the contracts visit. Therefore we have made a requirement regarding this in this report. The local authority contracts visit indicated that there had been a high number of falls that had occurred since the beginning of 2009, many not witnessed that mainly occurred during the night shift. We discussed night staffing levels, as currently there is one waking night carer and one carer on sleeping in duty. They currently have fourteen residents one of whom is high dependency and at risk of falls. The manager stated that night procedures have been tightened and they feel that the current night staffing level is adequate. She indicated that this would be reviewed as resident numbers increase. The contracts visit also highlighted that they did not have a contingency plan to cover staff sickness and absences at short notice. The manager indicated they have recently signed up with an agency to rectify this. Care staff are encouraged and supported to achieve their National Vocational Qualification (NVQ) in care level 2 or above. The AQAA indicates that five out of a staff team of ten carers have completed their NVQ level 2 or above. The staff training matrix only shows the mandatory courses. This indicates that not all of the care staff have completed their moving and handling training, which needs to be addressed. Some other mandatory courses also need updating. The contracts visit indicated that fire, first aid and medication training had been booked for staff to complete within the next few weeks. Care Homes for Older People Page 26 of 38 Evidence: We discussed recruitment procedures with the manager to see if the right number of security checks are carried out on new staff before they start work at the home. We looked at the staff file for the most recent carer employed to see if the checks specified in the National Minimum Standards and legislation had been done. This includes past employment checks, two written references and a police check. This is important to make sure that staff are trustworthy and safe to be around the residents living in the home. We found that the application form showed the employment history, the last employer reference was satisfactory and the police check had been returned prior to the start date. However only one written reference had been obtained. The manager said that the second reference had been a verbal reference, but this had not been recorded. At our last inspection we discussed that staff files must contain all the required information. Therefore we have made a requirement regarding this. Care Homes for Older People Page 27 of 38 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 are benefiting from the management improvements that have been made within the last six months. They have introduced quality monitoring procedures and practices that are starting to have effect and safeguard residents best interests. These now promote residents safety and provide them with adequate protection. However, the manager has not been proactive enough in this respect. They now need to make sure that the improvements are sustained and developed into a robust quality assurance system. Evidence: At our last inspection, we made two requirements under this outcome area. One was for a system to be introduced to evaluate the quality of the services provided at the home. This includes the regular monitoring of care practices, medications, staffing, Care Homes for Older People Page 28 of 38 Evidence: record keeping, the environment, complaints, safety procedures and obtaining the views of residents, their representatives and any other stakeholders. This should also include the providers monthly visits, as required under regulation 26, with the reports kept available at the home at all times. Any deficits identified should be addressed and records kept. This is to make sure that the home is run in the best interests of residents. We saw how they have met this requirement. Between April and October, they have carried out a range of monthly quality monitoring audits, including three medication audits, a kitchen audit, an infection control audit, an audit of the cleanliness of the home, an audit of residents accidents and a recent unannounced night spot check. We saw that they have acted upon the results. However, the accident audit and night check were only done recently as a result of the contracts visit. Also they had not notified the commission about the falls and serious injuries sustained by the resident previously referred to under section two, Health and Personal Care. This is something they are required to do under the regulations. (Regulation 37). We saw records of residents meetings for June, July and August, but these were not structured or planned with any forethought as to what was to be discussed. The result was that issues mainly related to things that would normally be dealt with by staff on a day to day basis, rather than drawing up an agenda and giving residents the opportunity to influence changes within the home. We saw that a staff meeting was held in September and covered care plans and daily records, training and infection control. We discussed that the implications of the Mental Capacity Act and DOLS should be covered at the next staff meeting. Quality assurance questionnaires were given out in March using the same questions as last year. These contained lots of responses indicating good and excellent for the areas covered. The manager had not analysed the results, but said that nothing needed changing as a result. She indicated that they would change the questions for the next survey. Although some of these things had been started prior to the contracts visit, it was not until after that visit that they carried out their falls analysis and took action to reduce risk. Management has therefore been reactive, rather than proactive in bringing about the necessary improvements. However it was clear that recently they have worked hard to address their deficits, which has kept the overall quality rating for the home as adequate. The AQAA indicates that residents financial interests are safeguarded. Our last report Care Homes for Older People Page 29 of 38 Evidence: states that the home does not handle residents monies and invoices relatives for any extra charges such as, hairdressing and chiropody. The contracts visit indicated that environmental risk assessments were not covering all areas within the home or detailing actions taken and any preventative measures put in place. The manager has been introducing a new format that has been downloaded from the environmental health website and provides much more detail. The second requirement from our last inspection was to make arrangements for all staff working at the home to be provided with all their outstanding mandatory health and safety training such as, fire safety, first aid and moving and handling. We have seen that staff have completed a significant number of mandatory courses and further are booked. However, the staff training matrix indicates that some staff still need to complete their moving and handling training. The manager needs to be vigilant in ensuring that any gaps in training are promptly addressed. The AQAA Dataset indicates that maintenance of equipment is up to date. Care Homes for Older People Page 30 of 38 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 38 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 4 14 The home must be able to 04/01/2010 demonstrate its capacity to meet the assessed needs of individuals admitted to the home. The registered person must confirm in writing to the service user that having regard to the assessment of their needs, the home is suitable and able to meet their health and welfare needs. This is to make sure that when a person is admitted to the home they can be confident that the home has fully considered all of their needs and has made a commitment that it has the ability to provide them with the right care. 2 7 15 Care plans must be reviewed 04/01/2010 at least once a month, updated as needs change and any action taken to Care Homes for Older People Page 32 of 38 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 address any changing needs. This is so that staff have all the up to date information they need to make sure they can give residents the right care and keep them safe. 3 8 13 Where a risk of falls is 04/01/2010 identified, the care plan and risk assessments must be reviewed and updated to make sure that any unnecessary risks to health and safety are identified and as far as possible eliminated. This relates to actions to be taken following a residents fall, making sure that records are cross referenced and transferred from the daily records and accident records into an updated care plan review, with actions to reduce risk clearly identified. e.g. increased monitoring at night from hourly to half hourly and review of the environmental risk assessment to remove hazards in the bedroom. Records must also show that medical advice or attention Care Homes for Older People Page 33 of 38 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 has been sought where necessary. To make sure that the health and welfare of all residents is promoted and they are kept safe. 4 27 18 There must be enough staff 14/12/2009 on duty at all times to meet the assessed needs of all the residents living in the home. This must include making sure that the weekend cleaner vacancy is filled and that there are enough care staff on duty on Saturday and Sunday afternoons and evenings to care for and supervise the residents plus prepare the evening meal. Night staffing levels to be kept under regular review and adjusted if residents needs change. This relates to there currently being one waking and one sleeping in carer on duty at night. This is to be adjusted to two waking night carers on duty every night if and when resident numbers and needs change. Care Homes for Older People Page 34 of 38 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 make sure that residents health, welfare and safety is protected. 5 29 19 The home must not employ 04/01/2010 a person to work at the home unless they have satisfied themselves that the person is fit to do so. This must include carrying out all the required recruitment checks, for example, obtaining two written references before appointing a new staff member and allowing them to start working with the residents. This is to make sure that the new staff member is trustworthy and safe to be around the residents. 6 33 26 The providers monthly visits 04/01/2010 must include interviewing a sample of residents and or their representatives, and a sample of staff to form an opinion of the standard of care provided at the home. The written report should show how many persons interviewed, with their status and initials. Care Homes for Older People Page 35 of 38 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 A copy of each monthly report to be supplied to the manager and copies of all reports to be kept at the home available for inspection if required. This is to monitor the standards in the home and make sure the home is being run in residents best interests. 7 38 37 All accidents, injuries and incidents of illness or other events in the home that affect the well being of the residents must be reported to the commission without delay and confirmed in writing. This specifically relates to the 5 accidents that a resident had between August and October 2009. This is to make sure that appropriate action is taken and followed up to keep residents safe. 8 38 13 Where a resident has a fall, 04/01/2010 a falls analysis must be carried out as soon as possible after the event to determine the cause and any remedial actions necessary to prevent further 30/11/2009 Care Homes for Older People Page 36 of 38 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 falls from occurring. This should then be used to inform the residents risk assessment and environmental risk assessments. The falls analysis should then be regularly reviewed and updated as necessary. This is to make sure that residents health and safety is protected. 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 12 To develop and implement an activities programme that makes sure residents can be offered stimulating activities to occupy them if they are not able to pursue their own interests without assistance. For this to be achieved they need to make sure that staffing levels are adequate to allow enough staff time available to organize activities when the activities person is off duty. Any complaints received should be recorded within the homes complaints and concerns records and show details of the investigation and outcome. For all care staff to receive training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). The manager to do this training without delay and for all care staff to complete during the next twelve months. 2 16 3 18 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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