Inspection on 17/09/09 for Orchard House

This inspection was carried out on 17th September 2009.

CQC found this care home to be providing an Poor 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

Orchard House 06/11/09

Orchard House 09/06/08

Orchard House 16/01/07

Orchard House 05/02/06

Orchard House 22/06/05

Orchard House 06/10/04

Orchard House 01/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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: Orchard House Orchard House Kinnersley Severn Stoke Worcestershire WR8 9JR     The quality rating for this care home is:   zero star poor 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: Sarah Blake     Date: 1 7 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Orchard House Orchard House Kinnersley Severn Stoke Worcestershire WR8 9JR 01905371445 01905371017 awilliar51@aol.com www.orchardhouse.co.uk Mr Anthony Gordon Williams,Mrs Susan Harris care home 39 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Age: Physical disability (PD) age 55 and above. The maximum number of service users who can be accommodated is: 39 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 39, Old age, not falling within any other category (OP) 39, Physical disability (PD) 39 Date of last inspection Brief description of the care home Orchard House is registered to provide residential care for up to 39 older people who may have a physical disability or a dementia type illness. Care Homes for Older People Page 4 of 34 Over 65 0 39 0 39 0 39 Brief description of the care home The home is an adapted country house with a purpose built extension situated in a rural setting. The home is about six miles from Worcester city. There is a local pub but no other amenities within walking distance. There is a regular local bus service. The home has ample car parking both at the front and side of the building. Accommodation is on two floors. People are able to access the first floor by means of a passenger lift, a stair lift or by using the stair cases. Handrails are fitted to assist mobility. On the first floor there are 16 single bedrooms, 9 of which have en-suite facilities, and 6 shared rooms, 4 of which have an en-suite. On the ground floor there are 7 single bedrooms, all of which have en suite facilities, and 2 shared rooms. There are 3 assisted bathrooms and 7 separate toilets throughout the home. People using the service have access to two communal lounges and a separate dining area. There is an accessible and well-maintained garden for people to sit in. Information regarding the current level of fees was not included within the copy of the Service Users Guide given to us at the time of our visit. The reader should therefore contact the service directly for up to date details. A copy of this inspection report is available to view at the home. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection. Two inspectors spent a day at the home, talking to the people who use the service and the staff, and looking at the records, which must be kept by the home to support good practice and to show that it is being run properly. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. We looked in detail at the care provided by the home for two people. This included observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this a Short Observational Framework for Inspection (SOFI). This involved us observing two groups of five people who live at the home for two hours each, and Care Homes for Older People Page 6 of 34 recording their experiences at regular intervals. This included their state of well-being, and how they interacted with staff members, other people living at the home, and the environment. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. Some of the managers comments have been included within this inspection report. We also received a completed survey form from a health professional who works with the home. The information from these sources helps us understand how well the home is meeting the needs of the people using the service. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: There is poor practice when staff are moving and handling people, and this could put people at risk of harm or injury. The home does not have adequate equipment to meet peoples mobility needs. Assessments and care plans do not adequately explain how staff can meet peoples mental health needs. This is especially important in a specialist dementia care service. Some medication procedures are not robust enough to ensure that medication, which has been prescribed to be given as required, is managed safely. Staff do not always treat people with the respect they deserve and should expect. The home does not provide activities which meet peoples individual needs. There is no evidence to show that activities are an integral part of peoples care planning. The environment does not support the needs of people of people with dementia, as there are no visual cues to help people orientate themselves around the home. There are some shortfalls in infection control. Care Homes for Older People Page 8 of 34 The homes recruitment procedures are not always followed, and this means that there is a risk that unsuitable staff could be employed. There is no evidence that staff have received all the training that they require to give them the skills and knowledge they need to care for the people who live at the home. The home does not always promote the safety and well-being of the people who live there. Unsafe practices mean that people could be at risk of harm or injury. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides information to help people decide if they wish to move to Orchard House. People can be confident that their needs will be assessed before they move in, so that staff know the care that needs to be provided. Evidence: The home provides detailed written information for people who are considering moving into Orchard House. This is in the form of a Service User Guide, which clearly sets out what people can expect from the home, and tells people what life is like at the home. There is no information to tell people if they can request the Service User Guide in other formats, such as large print or other languages. We spoke to the relatives of some people who live at Orchard House, and they told us that they had visited the home before their family members had moved in. They told us that the staff had made them welcome and that they had been given the opportunity to look round and to ask questions. One person described this initial visit Care Homes for Older People Page 11 of 34 Evidence: as a good chance to see what its really like. We looked at the records for one person who had recently moved into the home. We saw that the deputy manager had visited the person and their family before they moved in, so that a full assessment of needs could be carried out. This assessment told staff how they should support and care for the person as soon as they moved in. It also enabled the home to make sure that it was able to meet the persons individual needs. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot always be confident that their needs will be accurately assessed and met. The home ensures that people have good access to health professionals. Medication is generally managed safely, but there are some shortfalls. Peoples privacy and dignity is usually respected. Evidence: We wanted to see how the home plans peoples care so that it is tailored to their individual needs. This approach is called person-centred care. The Alzheimers Society explains how person-centred care works: Instead of treating the person as a collection of symptoms and behaviours to be controlled, person-centred care considers the whole person, taking into account each individuals unique qualities, abilities, interests, preferences and needs. Peoples care plans were clearly set out, and addressed all the areas of their lives at the home. All care plans are reviewed on a monthly basis, and amendments to the care plans are clearly marked so that staff can easily see if peoples care needs have changed. We saw no evidence that people living at the home or their relatives are Care Homes for Older People Page 13 of 34 Evidence: involved in the planning of their own care, as we would expect to see if care planning is truly person-centred. The home uses charts to monitor toileting, bathing and bowel movements. These are not individual charts, but lists of peoples names. They are institutional tools and do not support person-centred care. One of the senior carers has responsibility for reviewing and updating the care plans, and also for liaison with the GP and District Nurses. When we spoke to the local GP, he described this carer as genuinely caring, and told us that he values the continuity of her involvement. We saw that the home had carried out risk assessments to address some areas of concern. For example, one person had a risk assessment which stated that all toiletries should be kept in locked cupboards. This risk assessment was clear and detailed. However, during the inspection, we saw that cupboards containing potentially hazardous toiletry items were left unlocked. We say more about this in the Management and Administration section of the report. One of the people whose records we looked at needed a great deal of help and support with their personal care. We saw that their care plan stated cant walk with Zimmer any more but B (name of person) does manage to weight bear. It was clear from observation that the person could not bear their own weight. During the inspection, we saw three occasions where this person was being assisted by staff to transfer from one chair to another. On each occasion, staff used unsafe techniques, by dragging under the persons armpits. At the last inspection in June 2008, we saw that this unsafe technique was being used, and there appears to have been no improvement since then. When people are unable to bear their own weight, a hoist should be used to prevent any injury to themselves or to staff. The deputy manager, who was in charge of the home on the day of the inspection, told us that the home does not have a hoist, although they do have a stand-aid hoist. A stand-aid hoist can only be used where people are able to bear their own weight, so would not have been suitable for the person we observed. During the inspection, we saw staff carrying out unsafe moving and handling on two other people who were not able to bear their own weight. We spoke to a District Nurse, who told us that she would expect staff to be using a slide sheet to turn one person who is at risk of pressure sores. A slide sheet allows easy movement of the body on the supporting surface, as it reduces friction by allowing one layer to slide over the other. The care plan did not mention the use of a slide sheet. The deputy manager confirmed that staff were not using one, but Care Homes for Older People Page 14 of 34 Evidence: immediately instructed staff to start doing so. The District Nurse told us that staff at the home always follow any instructions from her and provide a good standard of care. She described the good care given to one person with a sore developing on their ankle. She said that staff had followed her advice and had provided good nutritional support, and that the sore had healed without any medical intervention. She also said that the home has a good record of pressure sore prevention. In the AQAA, the manager told us that nobody admitted to the home within the past twelve months has developed a pressure sore. Records showed that people living at the home are referred promptly for medical help if this is needed. One of the local GPs visits once a week on Tuesday afternoons for general medical checks, and more often if required. We spoke to the GP, who told us that the home is better than it has been - much improved. Because the people living at Orchard House all have dementia illnesses, it is important that their mental health needs are identified and met. We saw that the records for one person stated their mental health needs as severe confusion, but there was no information about how this might make them behave, or ways that staff could understand and support the person to minimise their confusion. During the SOFI, we saw that staff did not always interact well with people living at the home when carrying out tasks. For example, we saw a care worker putting a bib onto someone without talking to them or telling them what was happening. We also saw two care workers saying to someone come with us, with no explanation as to why. This shows a lack of understanding of the needs of people with dementia. We looked at the homes management of medication. We saw that any allergies were clearly recorded, both in the care plan and on the Medication Administration Record (MAR) sheets. The MAR sheets were generally fully completed with no gaps, and codes were appropriately used to explain why medication had not been given. We checked the records for three painkillers, which had been prescribed to be given as required. In all three cases, there were errors in recording which meant that it was not possible to audit the medications accurately. Some boxes did not have the date of opening recorded on them, and the home was not using a carry forward system, so that it was not possible to know how much medication had been left at the end of the previous month. The home stores medication safely, and has good procedures in place if people are able to take responsibility for their own medication. Care Homes for Older People Page 15 of 34 Evidence: During the inspection, we saw that staff generally treated people with respect, although there were occasions when staff failed to recognise and respond to peoples needs. For example, we saw that one person was visibly distressed and crying. A member of the care staff stopped and said You all right, C (name of person)? before moving away without waiting for a reply. Staff also referred to people who need assistance with eating as the feeders. The use of this term does not promote dignity. Care Homes for Older People Page 16 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a limited range of activities, which are not always matched to peoples individual needs. Meals are nutritious and provide a varied and balanced diet. Some people may not have their nutritional needs fully met. Evidence: In the AQAA, the manager told us that the home offers a varied activity programme tailored to the individual service users needs. We asked to see records of the sort of activities which the home provides. The deputy manager showed us a tick sheet which showed that the activities on offer the previous week had been: the hairdresser; garden or walk; in-house sing-along; external musician sing-along; and visits or phone calls. Records showed that five people had not been involved in any of these activities and nine people had only taken part in one activity all week. At the last inspection of the home in June 2008, we commented on the limited range of activities, and it is concerning that the home does not appear to have made improvements in this area. The Alzheimers Society states that Remaining physically and mentally active can have a significant impact on a persons well-being. During the day of the inspection, we saw many people just sitting in armchairs around the edges of the lounges for long periods of time. In the afternoon, there was a ballroom Care Homes for Older People Page 17 of 34 Evidence: dancing session, and we saw that some people were enjoying dancing with the instructor and with staff. While talking to some visitors, they commented about the activity taking place and asked if the home knew we were visiting that day, saying that usually not a lot happens. There was no information to show how activities are tailored to peoples individual needs, and no evidence of any understanding of the specific needs of people with dementia. The deputy manager confirmed that the home did not have any specific resources for people with dementia, such as reminiscence or sensory boxes. We would expect that a home which specialises in dementia care would be able to show how activities contribute to individual peoples well-being. As part of the inspection, we spent two sessions of two hours each, one in the dining room and one in the lounge. We used the Short Observational Framework for Inspection (SOFI), as explained in the summary at the beginning of this report. We saw that, although there were not many interactions between staff and the people who were being observed, the interactions which did take place were mainly positive. We saw records which showed that one person had been supported to practise their faith, and that the home had arranged for a priest to visit, as the person was not able to attend church services. People were complimentary about the food at the home, and we saw that the chef obviously knew peoples food preferences at breakfast, and provided for them as far as possible. Lunch on the day of the inspection was steak and onion pie with mashed potato, carrots, cabbage and green beans, followed by gooseberry sponge and custard. The deputy manager told us that, if people did not like the menu for the day, the chef would cook an alternative for them. Meals at the home are taken in two sittings, with the people who need assistance with eating being served first. We saw staff assisting people to eat, and this was done with kindness and patience. Staff were chatting with people as they helped them, and making sure that people were not rushed. We saw that one person was trying to eat their hot lunch with a spoon, and was struggling to manage to get any in their mouth. Ten minutes later, they were still struggling. A care worker sat down, mashed the food up and offered help, sitting next to the person. After a few mouthfuls, she moved away to help another person. Fifteen Care Homes for Older People Page 18 of 34 Evidence: minutes later, the person was still trying to eat their main course. Staff eventually took the main course away and gave them their pudding. The lack of support for this person meant that the main course must have got cold, and could have meant that the person did not have as much to eat as they would have liked. Care Homes for Older People Page 19 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that senior staff will listen to their concerns and respond appropriately. Staff know how to protect people from the risk of harm or abuse. Staff recruitment does not fully protect people from the risk of unsuitable staff being employed. Evidence: The deputy manager showed us the homes complaints procedure, which tells people how they can raise any concerns or complaints. We spoke to the relatives of some people living at the home, and they all told us that they would talk to senior staff if they had any complaints. Two people told us that they could not remember having seen the complaints procedure, so we looked to see if it was displayed in the home. We saw that it was pinned up on a wall near the staff workstation, but it had been obscured by other papers. One person told us about a concern they had raised with the home, and said that the manager had met with them and had explained how the situation had been resolved. Records showed that the home has received one complaint in the past year, and that this was resolved satisfactorily. We, the Commission, were notified about this complaint, and the home provided us with information about how it had been resolved. Care Homes for Older People Page 20 of 34 Evidence: Staff training records showed that staff had received training on the protection of vulnerable adults. Staff were able to describe how they would help to make sure that people living at the home were not at risk of neglect or abuse, and knew how to report any concerns. One of the ways in which homes can help to protect the people who live there is by ensuring that only suitable staff are employed. Staffing records showed that the homes recruitment procedures are not always followed, and this puts people at risk. We looked at the records for two new members of staff. We saw that the home did not have a current Criminal Records Bureau (CRB) check for one of them, and that they had received a poor reference from a previous employer. We say more about staff recruitment in the section on Staffing. Care Homes for Older People Page 21 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not provide an environment which supports good dementia care. The home is kept clean and tidy. People cannot be confident that infection control is always managed safely. Evidence: Orchard House is a country house which has been adapted and extended to provide a secure environment for people with dementia. The home has two lounges and a large dining room, and, in the AQAA, the manager told us that these had both been redecorated within the past twelve months. We saw that, in both lounges, armchairs were arranged around the edges of the rooms. This arrangement of chairs does not promote interaction between people, and gives an institutional feel to the room. The deputy manager explained that staff had tried to put them in smaller groups, but the people living at the home always moved them back again. There were no books or magazines in either of the lounges, and no reminiscence or sensory material, such as photo albums or scented plants. The deputy manager said that books are kept in the dining room, but that people arent interested in them. We saw that some areas of the home which are potentially hazardous, such as staircases, are only accessible through doors which have a key pad, so that only authorised people can open the doors. Because of the layout of the home, this means that some people who live there are unable to go to their bedrooms without the help Care Homes for Older People Page 22 of 34 Evidence: of a member of staff. A relative of one person told us that their family member had become very upset that they didnt have the choice of going to and from their bedroom as they wished. All the corridors in the home were painted the same colour, a pale cream. Whilst this means that the home looks fresh and clean, there is no way for people to know whereabouts in the home they are and there are no signs to help them orientate themselves, other than on toilet and bathroom doors. It is good practice in care homes for people with dementia, to provide some means, such as signage or differently coloured walls, so that people can more easily find their way around the home. We saw that bedrooms were kept clean and tidy, and that people had brought items of their own, such as photographs and ornaments, to give their rooms a more homely feel. Bedroom doors had small labels on with the name of the person whose room it was. There was no other way for people to identify their bedroom. It is good practice to provide some means for people to know which is their bedroom, such as a photo on the door or a picture of something which is important to the person. One shared bedroom had a curtain rail between the beds, but no curtain, so that the people living in that room would not have had their privacy maintained. The manager has since informed us that this curtain was being laundered, and that portable privacy screens would be available to ensure privacy. The bathroom and toilet doors had pictorial signs to help people identify them. The home has bathing and showering facilities, which include a Parker bath and a new wet room. We saw that some bathrooms and toilets did not contain any soap or paper towels. One toilet had a cotton towel for people to dry their hands on. The use of cotton towels in communal areas is not recommended, as it increases the risk of crosscontamination. The manager has since told us that the home does not recommend paper towels due to misuse by the people living at the home. It is the homes responsibility to provide adequate hand washing facilities which do not put people at risk of cross infection. There were other areas of concern about infection control which we observed during the inspection. For example, we saw one care worker take off her gloves and then go into the kitchen to wash her hands. This is not good practice as the kitchen should not be used for general hand washing. Care Homes for Older People Page 23 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes recruitment procedures do not protect people from the risk of unsuitable staff being employed. Staff training is not recorded and monitored effectively, and this means that people cannot be confident that staff have the skills and knowledge to carry out their work. Evidence: During the inspection, we saw that staff were generally kind and caring in their approach to people living at the home. One persons relative told us I feel theyre fond of him. Theres a bit of laughter there, but theres efficiency as well. There were five care staff on duty on the morning of the inspection, and the rotas showed that during the afternoon and evening this is sometimes reduced to four care staff. Although people told us that there were enough staff to meet their needs, one relative said probably I would have more available, and a healthcare professional told us some mornings you come here and theres hardly any staff on duty. The deputy manager told us that he was hoping to get more staff to cover busy times. During the SOFI, we saw that there were very few staff interactions with people living at the home which were not directly linked to their care needs. We observed that staff seemed very busy, and did not spend much time attending to Care Homes for Older People Page 24 of 34 Evidence: peoples mental health needs by chatting to them and generally providing companionship. As Orchard House is a specialist dementia care home, we would expect to see that staff time for meeting peoples mental health needs is given a high priority. We looked at the records for some members of staff, to make sure that their recruitment had been carried out correctly, and that they had the skills and knowledge they need for this specialist work. Records showed that one new staff member was working without a Criminal Records Bureau (CRB) check having been requested by Orchard House. There was no evidence that a POVA First check had been received. A POVA First check allows care staff to start work under supervision before a full CRB check is received. The deputy manager confirmed that a CRB check was not obtained for this employee and confirmed that no risk assessment was in place following some areas of concern identified in their previous CRB check. We saw that one staff members file did not contain references from previous employers, but only testimonials, which were not specific to the job description of a care assistant working with older people. Another staff member had been given a poor reference by their previous employer, and there was no evidence that this had been followed up at all, either by contacting the referee or by discussion with the staff member concerned. This shows that the home does not have robust recruitment procedures, and therefore people may be at risk because unsuitable staff could be employed at the home. In the AQAA, the manager told us that the home has stringent recruitment procedures in place and followed. This was not confirmed at the inspection. We looked at staff training records, and these were not up to date. At the last inspection, we recommended that an audit of training should be carried out and an action plan put in place. This has not been done, and as a result it was not easy to see which staff had attended training. It appeared from the records which we were shown that only two staff had received training in dementia care, but the deputy manager assured us that more staff had actually been trained in dementia care. Following the inspection, the deputy manager sent us a training matrix, but as it was blank, it did not give us any further information. Care Homes for Older People Page 25 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in a way which does not always meet the needs of the people who live there. Health and safety is not always managed effectively and this could put people at risk of harm or injury. Evidence: The home is managed by the registered manager, Lavinia Williams, and her deputy manager. They have worked together for many years, and are supported by a team of care staff, headed by two Team Leaders. The AQAA was returned to us when we asked for it. It gave some useful information, but large amounts of it were copied directly from the National Minimum Standards, so were not personalised to this particular service. Some of the comments in the AQAA were not accurate, and we have highlighted some of these in this report. At the last inspection, we recommended that the home should introduce a quality assurance scheme as a priority, so that the home could monitor the standards of Care Homes for Older People Page 26 of 34 Evidence: service provided and assess the outcomes for people using the service. It was disappointing to find that there has been no progress in this area. The homes Statement of Purpose says To provide leadership of the quality required, we will do the following: Install and operate effective quality assurance and quality monitoring systems. This is not borne out by the evidence. The home prefers people to take responsibility for their own or their relatives personal finances, and provides secure storage in every bedroom for this purpose. We looked at some of the homes policies and procedures. In the AQAA, the manager told us that the homes policy on abuse had been reviewed in April 2009, but the policy itself was dated as having been written in July 2002, and there was no evidence of review. The policy did not contain information about the local multi-agency guidelines on the protection of vulnerable adults, and was not in line with current good practice. The homes restraint policy was not in line with current good practice. One sentence in the policy referred to staff having to hold someone firmly by the hair. This is a practice which is not acceptable under any circumstances. We were concerned that some aspects of health and safety were not managed well. These put people at risk of harm or injury. For example, one persons risk assessment stated that all toiletries should be kept in locked cupboards, as mentioned in the section on Health and Personal Care. We saw that a cupboard in one bathroom was unlocked and contained potentially hazardous items, such as Optrex eye wash, in an unsealed container; steradent tablets; disposable razors and nail scissors. We saw the person in the bathroom by themselves as they waited for staff to assist them with bathing. We also saw that the cleaning cupboard was unlocked and contained items such as dishwasher powder, carpet shampoo and disinfectant. People with dementia may not always recognise items which could be harmful to them, and the home should make sure that any potentially hazardous items or substances are safely locked away. Two people living at the home had bed rails on their beds, and we saw that there was no written risk assessment to show why these were necessary and to ensure that they are used safely. The use of bed rails needs to be carefully assessed, due to the risk of entrapment if they are not properly used. As they are a form of restraint, in that they restrict a persons movement, there should also be a record that the person or their representative has consented to their use. We made an immediate requirement for the home to carry out these checks, and the deputy manager subsequently provided us with evidence that this had been done. Care Homes for Older People Page 27 of 34 Evidence: Orchard House is a specialist dementia care home, providing a service for people who are particularly vulnerable. Throughout the report we have identified areas of concern which show that the service is not meeting peoples needs. We have mentioned our concerns that peoples mental health and mobility needs are not being met, and that staff recruitment and the homes management of health and safety put people at risk of harm. These issues all relate to the management of the home, and none of them are being managed effectively. Care Homes for Older People Page 28 of 34 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 29 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 38 13 (4)(c) You must ensure that the use of bed rails is governed by a full written risk assessment, and that consent is gained for their use. This requirement has a timescale of 48 hours, therefore the date for compliance is 19/09/2009. This is so that people are not at risk of harm or injury. 12/10/2009 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 (1) You must ensure that 23/11/2009 peoples mental health needs are fully assessed and that care plans explain clearly how these needs will be met. This is so that people can be confident that their mental health needs will be met. 2 8 12 (1) You must ensure that an 22/10/2009 effective system is in place to manage peoples mobility needs. Care Homes for Older People Page 30 of 34 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 so that people are not at risk of harm or injury. 3 9 13 (2) You must ensure that records of the receipt, administration and disposal of medication are accurate. This is so that people can be confident that the home manages medication safely. 4 10 12 (4) You must put an effective system in place to ensure that the home is conducted in such a way that people are treated in a manner which respects their privacy and dignity at all times. This is so that people can be confident that the service will promote and respect their dignity. 5 12 12 (1) You must ensure that the activities provided by the home meet peoples individual physical and mental health needs. This is so that people are able to take part in social and leisure opportunities which meet their needs. 6 18 19 (1)(b) You must obtain in respect of all persons employed at the home all of 23/11/2009 23/11/2009 23/11/2009 23/11/2009 Care Homes for Older People Page 31 of 34 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 the relevant information and documents as required by Regulation 19(1)(b) and paragraphs 1 - 9 inclusive of Schedule 2 of the Care Homes Regulations 2001 prior to them commencing employment. This is so that people can be confident that only suitable staff are employed at the home. 7 30 12 (1) You must ensure that staff have the skills and knowledge necessary to provide care which meets the needs of the people living at the home. This is so that people can be confident that they will be cared for by staff who are trained and competent to do their jobs. 8 38 13 You must ensure that an 23/11/2009 effective system is in place to ensure that all parts of the home are safe for people who live there, within a risk management framework. This is so that people can be confident that they are not at risk of harm or injury. 23/11/2009 Care Homes for Older People Page 32 of 34 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 You should ensure that people who use the service and/or their representatives have been consulted about their plan of care and changes to the plan of care. You should consider more appropriate and person-centred ways of meeting peoples personal care needs than institutional charts. You should ensure that there is a choice of menus at each meal, so that people can exercise choice and control over their lives. Consideration should be given to finding out about and implementing the research that has been done about colour schemes and signage, so that people with dementia can more easily orientate themselves around the home and maintain their independence. You should ensure that records of training are up to date and support the planning of an effective training programme. You should ensure that you gain the views of the people who live at the home and their representatives, so that they can be assured that the home is run in their best interests. 2 8 3 15 4 19 5 30 6 33 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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