Inspection on 06/01/09 for Mountdale Nursing Home

This inspection was carried out on 6th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mountdale Nursing Home 28/02/08

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Mountdale Nursing Home 59 Mountdale Gardens Leigh On Sea Essex SS9 4AP     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: Ann Davey     Date: 0 6 0 1 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. the things that people have said are important to them: They reflect 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 31 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Mountdale Nursing Home 59 Mountdale Gardens Leigh On Sea Essex SS9 4AP 01702421019 01702511777 mountdalenursing@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Davinder Thakar,Mr Nathaniel Dogar Type of registration: Number of places registered: care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category terminally ill Additional conditions: Number of service users to whom nursing and personal care is to be provided must not exceed 22. (Total number not to exceed twenty two). Terminal Illness to include persons aged 55 years and over, to be provided up to and including 4 residents. (Total number not to exceed four). To provide personal and nursing care to 6 service users over the age of 65 years with a diagnosis of Dementia. Date of last inspection Brief description of the care home Mountdale Nursing Home is a purpose built establishment, situated in a predominately residential area of Leigh on Sea. A local bus route provides access to Southend on Sea Care Homes for Older People Page 4 of 31 Over 65 6 22 0 0 0 4 Brief description of the care home town centre. The home provides accommodation with nursing to twenty-two older people including the provision of care for people who have dementia. The residents accommodation is situated over three floors. There is a passenger lift to all floors within the home. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was a key inspection that took place over 8.30 hours. The visit started at 9.45am and finished at 6.15pm. The owner helped us throughout the inspection. The owner also manages the home on a day to day basis. They are in the process of making an application to us to become the registered manager as well as the registered owner. For the purposes of this report, they have been referred to as the manager throughout. The provisions Annual Quality Assurance Assessment (AQAA) had been completed and returned to us. This document provided the provision with the opportunity of recording what it did well, what it could do better, what had improved in the previous twelve months and its future plans for improving the service. Care Homes for Older People Page 6 of 31 We sent surveys to the provision asking that they be distributed and returned to us so that we could have an understanding of how residents, staff, relatives and health/social care professionals felt about the provision. Many of the surveys had been completed in a tick box manner, but there were no negative comments. We did not receive any completed surveys from staff or health/social care professionals. We were able to use some of the comments we did receive from residents and relatives within this report. The day spent in the home was very pleasant and everybody was helpful. The inspection process was undertaken with no difficulty. All matters relating to the outcome of the inspection were discussed with the manager who took notes so that development work could be started immediately where appropriate. The current weekly fee for the home ranges from 575.00 to 650.00 pounds. The actual fee depends on the bedroom facility (single/double) available or requested, assessed care needs and the source of funding (local/health authority or private). There are additional charges for items of a personal nature such as newspapers and hairdressing costs. What the care home does well: What has improved since the last inspection? What they could do better: As detailed in the report, the detail and information within most of the care plans and personal risk assessments we saw was inadequate. This means that the information on the care plans used by staff to provide care for residents, may not be current or correct. We noted that where personal risks had been identified, there were inadequate assessments in place to keep residents safe. The home is registered to provide care for residents with dementia. Improvements need to be made to the environment to make it more user friendly and safe. For example, there was a lack of signage or orientation aids and we saw boxes of vinyl gloves left in communal areas. The rear garden area is not secure as it leads directly on to the main road. The manager reported that work on securing this area was imminent. We also noted that there was an unguarded water feature in the rear garden. Care Homes for Older People Page 8 of 31 The manager was in the process of reviewing and updating all policies and procedures. Staff need to have up to date guidance on how to provide good quality care. The manager was not able to locate all the staff recruitment records we requested. The manager must be able to evidence that all staff are recruited and inducted properly to ensure that residents are safe. Although annual staff appraisals take place, there was no evidence that staff receive regular supervision sessions. The manager has made some progress on the homes quality assurance system, but further work is required. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are assessed before admission to make sure they can be met. Evidence: The homes Statement of Purpose, Service Users Guide and coloured brochure were updated in Spring 2008. Copies of these documents and a copy of the current inspection report were displayed in the entrance hallway. This means that prospective residents are able to read and understand what the home can offer and provide. One relative within their survey wrote there is a board when you walk in, that tells you all about the home. The pre-admission documentation of two residents admitted since the last inspection were viewed. Both had a clear pre-admission assessment document in place. One document had been completed in more detail than the other. The manager acknowledged this. Interim care plans had been put in place. It was clear to us that Care Homes for Older People Page 11 of 31 Evidence: the residents and their respective families had been involved in the admission process. The majority of residents had been admitted to the home directly from the hospital. This means that it is not always possible for prospective residents to visit the home before admission. The manager advised that families or friends of a prospective resident often visit the home on their behalf. This was confirmed by a relative within their survey. Currently, privately funded residents are provided with a contract of residency and local/health authority funded residents are provided with a copy of the Service Users Guide which outlines the Terms and Conditions of Residency. The manager agreed to review the Service Users Guide to ensure that the Terms and Conditions detailed within it complies fully with regulatory requirements. Care Homes for Older People Page 12 of 31 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 quality of care received by residents may be at some risk because it is not underpinned by a robust care plan documentation system or supported by up to date policies and procedures. Evidence: Five care plans and associated documentation such as risk assessments and incident records were looked at. With the documentation, there was evidence to support that residents (or their respective family) had been consulted about their personal wishes, preferences and the way in which they wished to be cared for. The home operates at least two different recording formats for care plans and risk assessments. This was confusing as the detail and style of recording was slightly different depending on what format had been used. We noted that where care needs had changed, it was the evaluation form that had been updated rather than the care plan itself. This meant that the information seen on care plans about a residents care need was not necessarily current. One resident was described as continues to have screaming episodes. When we asked about how this was being behavior pattern was being Care Homes for Older People Page 13 of 31 Evidence: managed, the manager told us that this was incorrect as the resident shouts through frustration. This was not recorded in their care plan. Another resident was described as aggressive. There was no care plan in place to help staff manage their care. One care plan recorded that bed rails were in place. The manager said that bed rails had never been in place. Another resident was described as diabetic. The manager told us that this condition had never been clinically diagnosed. Another resident was going through a very traumatic emotional experience, but there was no reference to this on the care plan. We were also left unclear about how staff monitor residents who are cared for in bed. For example, how often their position in bed needs to be changed and how this is recorded. The manager agreed that risk assessment documentation was not always current. Known risks such as the use of bed rails had not been properly recorded and generally risk assessment documentation was less than adequate. The manager agreed that the care plan and risk assessment recording system requires a complete review. The manager acknowledged that this may mean further training for staff who have responsibility for ensuring that the care planning and risk assessment system is current. Individual care records must reflect current assessed care needs, who is going to meet the needs, when they are going to be met, at what intervals and demonstrate that the care is regularly reviewed with any changes clearly recorded in the amended care plan. This must all be supported by a robust risk assessment documentation system. Residents can then be assured that their current care needs are clearly documented and all staff know what they are, how to met them and be aware of how to minimise known risk factors. We talked to the manager about how they were going to review and update the care plan and risk assessment documentation system. The manager agreed that this piece of work would be staggered using a priority risk assessment approach. The manager agreed that a system which meets regulatory requirements would be in place by the end of April 2009. The manager acknowledged that they have a regulatory responsibility to ensure that the delivery of care within the home must be managed safely. We looked at some accident/incident entries. The manager agreed to review the way information is transferred to the care plan documentation system to ensure that any additional care needs as a result of an accident/incident can be followed through by staff. This will be completed as part of the wider review process. We saw that daily nursing notes were in place. We spoke to various members of staff about care practices within the home. Those spoken with had an adequate basic understanding of individual residents needs. We noted that the rapport between residents and staff was warm, natural and supportive. Care Homes for Older People Page 14 of 31 Evidence: There was a lot of humour around the home. We noted that personal care practices were undertaken by staff in a dignified way. Residents were positive about the care they receive. We received comments such as lucky to be here, youll find no problems here, Id rather be in my own home, but Im safe and happy here, Im well looked after thank you. Within a relatives survey it was noted the families of the residents are always informed about the residents if there is any change. The manager reported that the home had a good working relationship with all social and health care professionals. A GP visited the home during our time there and was aware of our presence but did not wish to speak with us. We saw entries within the care panning documentation system demonstrating that appropriate assistance is provided when required. Surveys were made available by us for social /health care professionals to complete and return, but none were received. We sampled the medication administration, storage and recording systems and sampled various aspects for compliance. All aspects of medication practice within the home is undertaken by nurses. Each resident had a MAR (medication administrating record) sheet in place. There were no unexplained gaps in the records we saw. Routine day to day medicines were neatly stored either in the metal trolley, a locked cupboard or a designated fridge. There was no overstocking of medication evident. All medication was stored in a designated locked room. The manager agreed to review the siting and position of the Controlled Drugs storage cupboard. New controlled drugs storage requirements are now in place and it was unclear if the home was in compliance. The manager will take advice about this and ensure that the storage is compliant with current requirements by the end of April 2009. We noted that apart from one medicines policy which was dated 2001, all the other policies and procedures used by nurses dealing with medication were not dated. Our observation from the colour and condition of the undated policies and procedures was that they may be quite old. The nurse assisting us told us that this was the guidance used. The manager told us later that more up to date policies and procedures were available. We explained that the documents used by the nurses were the ones seen by us in the medicines room. The nurse had confirmed this to us. The situation needs to be reviewed by the manager so that the nurses undertake all medication practices safely and in keeping with current legislation and guidance. The manager agreed to review medications practices within the home to ensure that the storage, administration and recording of medicines is correct. The manager also agreed to review all medicines risk assessments, for example, self administration, oxygen cylinders in residents bedrooms and PRN (as/when) as part of the ongoing care plan review. The manager acknowledged that all medicine practices within the home must be safe and in line with current requirements. We told the manager about the Care Homes for Older People Page 15 of 31 Evidence: information and guidance on medication practices on our internet website and also advised that consultation with other associated professionals may be helpful to them. Care Homes for Older People Page 16 of 31 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. Residents benefit from good diet provision and a developing social activity programme Evidence: The manager reported that the vast majority of residents had contact with either family or friends. During the day there was a steady stream of visitors. We did not get the opportunity to speak to any visitors individually, but we did receive five completed surveys from them. We had displayed a notice in the entrance hallway advising all visitors that we were available to speak to anyone if they wished. A resident was celebrating their birthday and was clearly enjoying the attention from the other residents and staff. A special small table had been cleared in the lounge area to display the cards and at morning coffee time, a birthday cake with candles was brought in and all the staff gathered to sing happy birthday. Most of the bedrooms were single occupancy, but there was provision in the home should a resident wish to see their visitors in private. Residents told us that although they dont go to church, they would feel comfortable about asking staff to see a representative of a local church or faith. As we looked around the home we saw that residents personal beliefs and faiths were recognised Care Homes for Older People Page 17 of 31 Evidence: and acknowledged because of the belongings and decoration in some bedrooms. From our conversation with residents and from the comments in their surveys, all indicated that within reason, they are able to exercise choice and control over their personal lives within the home. During our visit, we noted that staff were providing residents with choice about a number of things. For example, meal portion size, choice of drink, were they hot/cold. Since the last inspection, the manager had begun to develop the daily activities programme. The programme still remains quite limited, but there was progress. There was now at least one organised activity each afternoon. Residents told us that they liked what was being organised, but intimated they would like more variety. The manager told us about how the programme is to be developed and was able to demonstrate that they are actively seeking resources. The manager acknowledged that the home is registered to provide care for residents with dementia and some residents are cared for in bed all the time. As part of the development, the manager must make sure that all residents are provided with appropriate occupation, activity and stimulation. The daily menu was available and displayed. We saw that residents had been provided with a choice of food at all mealtimes. The chef had kept a brief daily record of what each resident had chosen or been provided with. The manager acknowledged that these records should include more detail. For example, the quantity eaten and what was eaten. Some records had just the words roast or liquidised without proving any further detail. The manager told us that the chef does not always keep to the printed menu and an alternative may be provided which is not on the menu. This was confirmed to us by the chef. Should there be a query about a particular residents nutritional intake, the manager may have some difficulty in providing any helpful detail. Lunch looked most appertising and liquidised meals had been attractively presented on plates by the chef. Residents told us that they liked to have their meals either in the bedrooms or on a small table whilst sitting in arm chairs. Dining tables were available, but those residents spoken with said they preferred to stay where they were. We noted where residents required assistance by staff to eat their lunch, it was being undertaken in a sensitive way. We received the following comments from residents about food, the food is beautiful, I can have my dinner where I like, food is good and plenty of it, could be hotter when I get it, but its ok, wish the gravy was hot as it spoils the lovely food. One residents survey recorded the food is well cooked, prepared and plentiful. Care Homes for Older People Page 18 of 31 Care Homes for Older People Page 19 of 31 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. Residents are cared for in an environment where there is provision to raise concerns and feel safe because adult protection procedures are known by staff. Evidence: The homes complaint procedure was displayed in the main entrance hall way. It was also within the Service Users Guide. Some residents and relatives within their surveys reported that they were not aware of the procedure. We however, found the procedure was readily available. It is possible that residents may not be aware of where to find the procedure or be aware of its content. Those residents we spoke with told us that they would feel comfortable about raising any issue with a member of staff and would be confident that it would be dealt with appropriately. One resident survey reported (if I have a problem) I just ask to see the head matron who normally deals with it. In the entrance hallway, the home has a box with complaints/suggestions on it. Should somebody wish to raise an issue anonymously, the home has made provision. The manager showed us where any complaint would be recorded. Within the record we saw three entries since the last inspection. The records were clear and provided details of the concern, date, the action taken to investigate, the outcome and concluding comments from the complainant. We discussed the nature of the three entries. We concluded that two were areas of concern that had arisen because of possible misunderstood terminology used by a member of staff and a Care Homes for Older People Page 20 of 31 Evidence: misunderstanding between two professionals. The third entry was referred to the local authority as it was an adult protection matter. This was about a suspected poor care practice. We saw the concluding letter from the local authority following their investigation which was reported as unresolved. The letter stated that the local authority will continue to monitor practices within the home. We looked at the staff training schedule and saw that staff have attended adult protection training courses. We spoke to two nurses and one member of care staff about their understanding of reporting any suspected adult protection incident. One nurse was clear about the correct procedure, the other nurse said that they would report it to the manager and the member of care staff said they would tell whoever was in charge. The manager was clear about the homes responsibility to refer all matters to the local authority immediately any incident was suspected. Care Homes for Older People Page 21 of 31 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 live in a comfortable, clean home. Evidence: The home was furnished and decorated to a good standard. The lounge/dining areas were comfortable and homely. Those bedrooms seen were personalised and homely. We thought that some bedrooms were quite sparse in that apart from a bed, table, TV and clothing storing facilities, there was nothing else apart from some personal memorabilia. The manager told us that these rooms need to be kept free from unnecessary items as the floor area was in constant use because these residents were nursed in bed. The manager assured us that if the resident or their family required additional furniture, it would be provided. Bathroom and toilet areas were clean and functional. The laundry, kitchen and sluice areas were clean and tidy. The front and rear garden areas were well maintained and attractive. Corridors, stairways and communal area were clear and free from hazards. There were some hoists and wheelchairs stored in the corners of some hallways and corridors, but there were no trailing leads or jutting out pieces of equipment. The manager said that these areas are not used by residents and pose no risk. The managers office and the nurses office were orderly and all information or documentation requested was readily available. The homes entrance hallway was particularly pleasant. There was a small table, easy chairs, an orderly notice board with plenty of information and advice, a booklet/small Care Homes for Older People Page 22 of 31 Evidence: books/brochure display, a suggestion box for comments and details of the local advocacy service. Odour control through the home was well managed. The manager showed us the plans that had been submitted to the local authority requesting planning permission to build a new lounge area to the back of the home. If planning permission is granted and the extension is built, this will provide a very pleasant lounge for residents use as it will overlook the rear well maintained garden. The front garden can now be used by residents as the area has been made secure. The rear garden was not secure as residents using it have direct access to the main road. This was raised at the last inspection. The manager was able to demonstrate that arrangements are in place for the rear garden to be made secure before the start of the spring/summer season. Currently, residents wishing to use the garden have to be accompanied by staff at all times because of the adjacent main road. The home is registered to provide care for residents with care needs associated with dementia. The manager acknowledged that there there was little signage and orientation aids to assist these residents as they move around the home. There was a waterfall feature in the rear garden which could pose a risk to unsupervised residents and we noted that boxes of vinyl gloves which are used by staff had been left in bathrooms and toilets. Measures must be put in place to ensure that the environment is safe for all residents. The manager said that these measures would take immediate effect. Residents told us I like my room, theres always something going on in here (the lounge), my room is kept nice, if I feel cold, they sort it out, Im comfortable and like being in my own room. One residents survey reported the rooms are very tidy and clean and theres hardly any nasty smells. Care Homes for Older People Page 23 of 31 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 are cared for by a team of trained staff but may be at some risk because not all documentation was available to support the management of a robust recruitment process. Evidence: A current and clear staff rota was available. The managers hours were not recorded, but this was addressed immediately. The rota showed us that there were a minimum of four care staff, a nurse and the manager on duty during the day and two care staff and a nurse on duty at night. In addition, the manager works most days 10am - 6pm and there are domestic and cooking staff on duty every day. The manager confirmed that numbers of staff on duty do not fall below these levels. The home has its own bank of staff to call upon and apart from one shift over the Christmas period, had not used any agency staff since spring 2008. The manager told us that they are in the process of reviewing staff shifts patterns and duration to ensure that there is adequate time for a detailed handover period from one shift to the next. They felt that this would improve communication. Also, the manager is addressing the length of some shifts currently worked by staff. On the rota some staff had worked twelve hours shifts on a regular basis. The manager explained that this had been through the individual member of staffs personal choice, not through any pressure from the management. The manager reported that the current staff group is stable and reliable. There were Care Homes for Older People Page 24 of 31 Evidence: no staff vacancies. This means that residents were benefiting from being cared for by a team of established staff. Within some surveys residents and relatives told us that they had experienced some communication difficulties with staff whose first language was not English. We discussed this with the manager who was already aware of the issue and had addressed them by providing further training. We received no further comments about this when we spoke to residents. We saw a detailed current staff training matrix in place. The manager reported that two staff have NVQ 2 with another eight staff shortly to finish and four staff have NVQ level 4. All nurses employed are Registered General Nurses. We saw records of staff appraisal sessions, but the manager could not evidence that there was an established staff supervision process in place. The manager and one of the nurses had booked to attend an imminent eight day Mentor Workshop based on Learning and Assessment in Health and Social Care run by Anglia Ruskin University. Staff on duty wore practical uniform style dress. We viewed at random the recruitment records of two members of staff. The manager could not locate either of the two references from the first set of records and confirmed that only one reference had ever been received on the second. We recognised that the failure to locate the first two references was probably an administration error as all other documentation in this file was in place. The manager acknowledged that the second reference on the second file had not been taken up. We saw that both members of staff had commenced their programme of induction, but had not progressed further on the modules other than completing the first day orientation aspect. The manager assured us that now the Christmas and new year holidays were over, further work would be carried out on their induction programme. Staff working in the home must be properly recruited and inducted to ensure that residents are safe and protected. The manager showed us records of recent staff meetings. Staff told us that they were happy working in the home, they felt supported by the manager, enjoyed the training opportunities and felt that there was a good team spirit. Residents told us staff are so nice, theres always somebody around to help me, theyre ok, theyre kind and nice to me. One resident survey reported staff are always polite and seem very kind and caring, another reported the staff are very good here and the matron keeps them on their toes. Care Homes for Older People Page 25 of 31 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. Residents are cared for in an environment where their care needs are managed well but may be at some risk because the management of care planning documentation needs to be improved to ensure that the care is delivered safely. Evidence: Since the last inspection, the manager had made an application to us for registration. The manager is also the registered owner. We experienced no difficulty in locating the documentation, letters and reports requested as part of the visit. One resident survey told us on the whole, (the home) is well run. The home has a generic environmental and a safe working assessment folder in place. There was also a COSHH (Control of Substances Hazardous to Health) in place. The manager agreed that both documents should be reviewed and updated. The information was not adequate to inform staff about any known risks and how to minimise them. We gave advise and guidance on how to obtain assistance in this. As Care Homes for Older People Page 26 of 31 Evidence: detailed in this report, the manager stated that they were in the process of updating all polices and procedures within the home. Policies and procedures provide staff with advice and guidance on good practice. It is important that these documents are available as quickly as possible to ensure that practice within the home is based on current guidance. We saw evidence that staff had annual appraisals, but there was no documentation to evidence that formal supervision takes place. The manager agreed to implement this with immediate effect. We saw infection control and safety notices displayed around the home. The home had a current fire risk assessment in place. We saw a letter to support that the Fire and Rescue Service had carried out a satisfactory routine visit on 15th August 2008. Environmental Health Services have not visited the home since it was registered in 2007. There were records in place to demonstrate that regular fire drills and checks on the fire alarm system had been undertaken. Other maintenance and service records were viewed at random and noted to be current. For example, lighting hoists, passenger lift and gas safety certificates. We saw records to support that staff, relatives and residents meetings had taken place. This means that stakeholders have a forum by which to voice their views and opinions. We saw that as a result of the last meeting, the menus had been reviewed and changed. Residents told us that they felt comfortable about raising suggestions and pointing things out. Our records show that the home notifies us about incidents as appropriate. The home looks after residents personal monies if requested. The system used by the home had a good audit trail. The manager advised that they are currently preparing stakeholder surveys to be distributed. Following this a quality assurance report will be in place and available. The manager agreed to make this available by June 2009. Care Homes for Older People Page 27 of 31 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 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Every resident must have a detailed plan of care in place. These documents must include all aspects of personal and health care as detailed in the national minimum standards and make reference to any current and appropriate risk assessments. Without adequate current documentation, staff may not be aware of assessed needs or how they should be met 30/04/2009 2 29 19 Residents must be protected 31/01/2009 by staff who have been subject to a robust recruitment check. This includes providing two satisfactory references. To ensure that residents are kept safe Recommendations Care Homes for Older People Page 29 of 31 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 The manager should continue to develop the social activity programme and ensure that the assessed needs of all residents are considered and met. Environmental risk assessments should be in place to ensure that all residents are kept safe both inside the home and outside in the rear garden area and that appropriate signage is displayed to assist residents who have care needs associated with dementia. There should be a robust quality assurance system in place and an annual development plan developed All staff should have structured supervision sessions at least six times a year Policies and procedures should be current so that staff have up to date information and guidance to base their practice on. 2 19 3 4 5 33 36 37 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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. 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