Inspection on 12/06/09 for Orchard Lea

This inspection was carried out on 12th June 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orchard Lea 17/09/08

Orchard Lea 07/08/07

Orchard Lea 16/06/06

Orchard Lea 07/03/06

Orchard Lea 23/11/05

Orchard Lea 30/03/05

Orchard Lea 29/11/04

Orchard Lea 30/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Orchard Lea Orchard Way Cullompton Devon EX15 1EJ Lead Inspector Louise Delacroix Key Unannounced Inspection 12th June 2009 09:00 DS0000039280.V375749.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 2 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 Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Lea Address Orchard Way Cullompton Devon EX15 1EJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01884 33375 01884 33375 http/www.devon.gov.uk Devon County Council VACANT Care Home 26 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (5) Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th September 2008 Brief Description of the Service: Orchard Lea is a local authority (Devon County Council) care home which is currently registered to provide accommodation together with personal care to up to 26 older people, up to five of whom may also have a physical disability and up to five of whom may also have dementia. The home was originally built with thirty-six bedrooms. Ten of them are now either used for office space, visitors’ rooms or storage. There is level access into and throughout the building. There is a shaft lift between the two floors and adapted bathrooms and toilets accessible to people with physical disabilities. Each floor has its own lounge and dining areas. The first floor has a quiet room. The weekly cost is a set fee of £570.50. Extra costs include dry cleaning, hairdressing, dentist, optician and chiropodist (unless NHS funded), private telephone lines, pet costs (if pets are agreed) and newspapers/magazines. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . The last inspection report is on display in the main entrance hall Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was brought forward in response to safeguarding concerns and a complaint that had been made about the care; because of the timescales the home did not complete an Annual Quality Assurance Assessment (AQAA).This document would normally be completed before a key inspection. Three inspectors carried out this inspection, including a Pharmacy Inspector. Prior to our visit we sent out surveys to health and social care professionals that visit the home. We received four surveys from visiting GPs but did not receive feedback from the district nursing team or the adult community services team. We also gave out surveys to three relatives that we met during our visit. As part of our inspection, we spoke with people living at the home and observed the care they were given to help us judge the quality of the care provided. Staff members spoke about their roles and responsibilities, and their views are contained in this report. The inspection was unannounced and took place over nine and half hours. We were told that there were twenty people living at the home, including one person on a respite stay. As part of the inspection, six people were case tracked; this means that where possible these people were asked about their experience of living at the home, their rooms were visited and the records linked to their care and stay inspected. During the inspection, a tour of the building took place and records including care plans, staff recruitment, training and medication were looked at. What the service does well: People told us that the care staff are caring, ‘good fun and lovely’. People told us that the food provided is appetising. People said that they like their rooms and are satisfied with the way they spend their time. The temporary management team are providing positive role models and are promoting best practice within the home. What has improved since the last inspection? The home has invested in new beds and a new carpet has been fitted on the stairs. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 6 The home no longer provides support for the nearby bungalows, which means that the staff group are dedicated to the home. What they could do better: As a result of the inspection, we have made a number of requirements to ensure that the quality of the care provided improves so that people living at the home have their health and welfare protected. These all have timescales attached to them and we will monitor Devon County Council’s compliance. We made requirements to improve the way that the home assesses people planning to move to the home to ensure they can meet their needs prior to them moving to the home. Orchard Lea must improve the quality of their care planning to provide guidance to staff and to ensure that people living at the home are involved in the way they are supported. The home must address gaps in the way that people’s health needs are managed or monitored. To promote safe practice, we have made three requirements linked to the way medication is managed and administered. This is currently unsafe and puts people at risk. The home has to improve its management of complaints and the recording of them. And how staff are recruited needs to be improved to help ensure that the home is a safe place to live. Staff need to have access to regular supervision to help monitor their performance and their training needs. Currently, there is not a robust quality assurance system in place and this means that not everybody who has contact with the home can influence the quality of the service. The management of people’s finances are not robust and do not offer adequate protection to people living at the home. We must be informed in a timely manner of changes to the home’s adverse events at the home so that we can monitor how people are being looked after. We also made a range of recommendations that promote best practice. These relate to meeting people’s communication needs and involving people in their care planning i.e. around bathing, spiritual needs and advance planning for end of life care. There needs to be robust systems to monitor people’s food intake and weights, and how medication administered by health professionals is recorded and storage temperatures for medication are measured. There should be an assessment of staff competencies with the provision of appropriate training to support them to do their job. The home would benefit from a manager who has been registered with the Commission to help ensure they are competent for the role. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 7 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. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 3 and 4. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people moving the home cannot be assured that their needs will be met due to inadequate planning and assessing. EVIDENCE: We looked to see how the home ensured that they could meet people’s care needs before they move to Orchard Lea. We looked at the admission process for two people who have moved to the home since the last inspection and saw that there was poor planning about how people’s needs would be met. One person had stayed at the home on a regular basis for respite but had then moved to the home on a permanent basis. However, this was not clear from the paperwork and there was no acknowledgement about the emotional needs of the person now that their move had become permanent. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 10 Another person had moved to the home on a permanent basis despite there being no plan in place to meet their communication needs, which we saw left staff struggling to ascertain the person’s needs and wishes, and left the person isolated. Staff told us they were concerned about how they could only communicate on a very basic level, particularly when the person needs help to control pain. We observed these communication difficulties during the inspection. A staff member from the temporary management team told us that they had been to visit two people due to stay at the home on a respite basis. They told us that they had liaised with other professionals involved in each person’s care to help them assess their care needs. We saw paperwork that reflected this shared information. However, the paperwork completed by the home is not clear about who has been involved in the collation of information, and its main focus is on people’s physical needs rather than taking a holistic approach. We were shown new documentation that will help combat this. The six care plan files we looked at contained a range of forms, some of which had been used to help gather useful information about the person and their care needs. However, many of the forms were undated and therefore it was not possible to establish when the assessments had been carried out. Most files we looked at also contained a copy of an assessment carried out by a Social Services care manager giving a brief outline of the reasons why the person was moving into Orchard Lea. We looked to see if the staff at the home have undertaken suitable training to meet their diverse needs. The home is registered to care for five people with dementia but not all of the staff have received this training, which was confirmed by records that we saw on the day, and discussion with staff. We observed that while staff were caring in their approach, sometimes the speed of their questions were not paced to meet the needs of the person with dementia. On several occasions, a staff member gave too many options, which left the person unable to keep up with the pace and led them to stop the task they were undertaking. However, other staff showed a greater understanding on how to pace their approach and to take time to listen to the person. Staff also told us about the care needs of someone with significant mental health needs, which impacted upon their motivation and ability to participate in the life of the home. The home is not registered to meet the needs of people with mental health needs if this is their predominant care need. Records show that staff have not received training in this area of care, and staff told us that they were concerned that the home was not a suitable environment for the person. We heard in a staff handover that this person’s specialist activity programme was ceasing. We were told that the new management team had recognised staff concern, and that a review had taken place with a community psychiatric nurse to look at the person’s care needs and whether they were being met on appropriately. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 7,8,9,10 and 11. People using the 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 planning and delivery of people’s care at Orchard Lea is poor. People’s dignity, health and wellbeing are placed at risk by poor recording and planning, and a failure to maintain safe systems for administering medicines. EVIDENCE: Despite repeated requirements on previous inspections and the beginnings of improvement at the last key inspection, the quality of care planning has deteriorated to a poor standard. Care planning should provide a foundation to good quality care to ensure that people’s physical and mental well being is supported in a consistent manner. However, we saw in the daily notes for one person that they were struggling to come to terms with the permanency of their move to the home but there was no current care plan to guide staff how to support them. Staff told us they felt compromised in what they told the person about their stay because of a lack of clarity over how much the person had been involved in the decision. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 12 We looked at five care plans in detail and none of them provided clear guidance about the person’s needs. At best, they provided generalised information but on the whole they lacked clear guidance about key areas of care. For example, one person had fallen on numerous occasions but there was a lack of evidence in the care plan to show if consideration had been given as to how to reduce or manage this risk. For the same person, a risk of urinary tract infections was documented but there was no guidance as to how this could be managed or the risk reduced. We were told by staff that the person had a specialist mattress but there was no care plan that mentioned this equipment, the reason for it or how the person’s skin should be cared for despite the use of the equipment suggesting that their skin was at risk of deteriorating. Each care plan file contained a form entitled ‘Personal Requirements’. This form was intended to give care workers an overview of the person’s usual daily routines and was set out in four sections (morning, afternoon, evening and night). The level of information in these forms was limited and failed to give basic information on many aspects of each person’s daily routines. The care plan files also contained a form entitled ‘Holistic Care Plan’. The files we looked at contained lists of tasks to be carried out, but very little detail about how the person wanted to be helped with these tasks. For example, the files did not show people’s preferred times of rising or going to bed, whether they wanted to have a bath, shower, or daily strip wash. Many of the daily reports completed by care workers stated ‘All personal care given’. It was therefore difficult to gain a clear picture of the help each person needed, or if they received a consistent level of help every day. None of the care plans showed that the person living at the home had been involved in the content, which is not best practice. Many of the forms used in the care plans files had not been dated and there was no evidence to show that the information had been reviewed. This meant that it was not possible to see if the information was up to date. We looked to see if health risks that staff had identified when talking with us were reflected in people’s care plans but saw that this was not the case. If records were kept, they were inconsistent and subjective and were therefore not robust in measuring and reducing the risk. For example, we saw that staff were recording the meal intake of several people but when we looked at one of these people’s care plan there was no guidance linked to this practice. We talked to staff about how food intake was recorded, we saw from records that this was often done in a subjective manner i.e. ‘very small amount’ or ‘tiny’. These records only went up to 5pm, which means that according to the Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 13 records, people had a gap of over twelve hours without food despite being identified as at risk of weight loss. However, staff and the daily records for other people told us drinks and food are offered after this time. This means the system is inaccurate. We asked several staff where the weights were recorded for these individuals and were told that this would be in the bathing records, we saw that weights were not regularly kept even for people who were having their food intake monitored. Staff told us that the home had appropriate equipment to weigh people even if they cannot weight bear. We saw bed rails in someone’s room, and a completed chart for hourly checks by staff at night. We saw from an accident record that the person had fallen out of bed in May 2009. However, there was no clear link in the care plan between the use of bed rails and the fall, although daily notes showed this equipment was fitted on the advice of the district nurse. There was no recorded risk assessment regarding the use of the rails, their appropriateness and how the fitting would be checked to ensure the equipment was safe. There was no record of involving the person in a discussion regarding the use of the rails, or whether they had capacity to be involved in this decision. From talking to the temporary management team and from looking at records we could see that where they had recognised potential risks to people’s health they had begun to address them i.e. requesting training for care staff from the district nursing team to address health issues that have been identified. The district nursing team have confirmed this training will take place in September 2009, and that they are receiving more requests for advice. We looked to see if the home’s management of medication kept people safe and well. We found that practice needs to be improved. For example, we saw from the daily notes of one person that health problems had been identified but are not always followed up so that there is no regular oversight of the concern and no clear aim of how it will be managed. Their records showed on 24th February 2009 the daily note state for one person ‘areas still looking red and dry’, the next entry 27th February 2009 ‘need assistant with cream’, the next three entries on 2nd, 6th and 7th March 2009 do not mention the person’s skin condition. It is not until the 11th March 2009 that the comment ‘still looking a little red…’ We saw from medication charts in the rooms of two people that staff are not signing on a regular basis that medication is being given i.e. prescribed creams/ointments or eye drops, which means that people do not receive consistent care to manage their health needs. We were not able to ask these people directly about their health because of their communication difficulties. We looked at the care plan for one person that contained contradictory information. For example, one undated form said that the person was too Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 14 confused and had difficulty reading labels to self medicate but another form records that the person is self medicating. We were told that there had been an occasion when medication had not been provided as prescribed, and that a person had to request for their pain relief patch, which is a controlled drug, to be changed. The temporary management team said that this matter had been addressed with the staff member and that disciplinary procedures had been followed. We observed the administration of medicines during breakfast and saw that people were asked discretely if they required either pain relief or aperients. The administration was recorded after people had received their medicines, and it was seen that when medicines were prepared before the person was ready that this supply was disposed of and a fresh supply prepared when they were ready for their medicines. We looked at the medication administration record (MAR) charts and found some discrepancies on these. For one person a hand written chart had been prepared but the dose recorded on the chart did not correspond with the dose printed on the dispensing label. The hand written entry only had one set of initials present which indicated that it had not been checked by a second person. We were also told that at present there is no system in place to verify the current dose of a medicine with the prescriber on admission to the home. Whilst this may not present a problem for people admitted from a hospital or other care setting it does present problems for people admitted from their own homes. We found that for most people there is a record present of all medicines received into the home and also for disposal if no longer needed. However we found that for those people leaving after a respite stay that there is no record made of medicines that are taken back out of the home. We found that the home had a medicines room and locked cupboards for the storage of medicines. However, not all medicines were seen to be stored securely and we also found that the home did not have storage meeting current regulations for Controlled Drugs. An immediate requirement was issued for the home to obtain and install such storage. We have since received confirmation that the cupboard has been ordered. Within the existing cupboard we found that not all controlled drugs had been recorded in the register, whilst we were present the staff at the home corrected this. We also found that there was no record of administrations of these medicines present in the home as they had been administered by an external healthcare professional. There is a dedicated medicines fridge and the temperature of this was seen to be monitored and well controlled. However no temperature monitoring of the medicines room takes place and we found that the heating was on in this room Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 15 so this may mean that medicines are being stored at temperatures greater than those recommended by the manufacturers. We found for some people prescribed that the printed dose intervals for medicines containing Paracetamol was not in accordance with the published dose guidance. This was discussed with the people administering medicines who confirmed that they administered at the dose intervals indicated. This may pose a potential risk for the people receiving these doses. Whilst we were at the home a member of staff contacted the supplying pharmacy and requested that they review the printed dose interval. For some people we found that the MAR charts had some medicines recorded as not administered because they were out of stock. We asked how stock levels were monitored and ordered to ensure this situation was prevented. We were told that at present there is no system in place but that an audit chart had been prepared for introduction from 15/06/2009. Four GPs told us that the home seeks advice and acts upon peoples’ health care needs. We looked to see if people’s dignity and privacy was respected. We heard people being called by the names that they told us that they preferred. We heard people being discreetly helped to the toilet and being asked how they would like their food prepared. Another staff member told us how they discreetly managed people’s personal care needs when infection control measures were needed in order to protect the person’s sense of pride and dignity. When we spoke to people living at the home, they indicated that they were happy with the way that staff treated them. One person told us that the staff listened to them and that they were ‘marvellous’. Another person told us that they had to behave but that they felt safe. We observed the body language of people who were not able to converse directly about the way they were supported and they generally looked relaxed with staff and in their surroundings. However, care plans do not contain enough detail to help maintain people’s dignity and privacy. For example, relating to personal care, instead of individualised details the ones we saw stated ‘needs help with personal care’ but did not record individualised preferences. We looked at bathing records for people living at the home; these showed that baths were only offered on an intermittent basis, and this does not promote people’s dignity. For example, one person who is recorded as enjoying their bath on each recorded occasion only had access to this support twice in February and twice in May 2009. A second person only had two baths in December 2008 and one bath in January 2009. Staff confirmed that the home is equipped with suitable equipment to provide baths even for people with mobility difficulties. We saw a diary entry dated 22nd May 2009 asking why Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 16 people had not had baths, which showed that the temporary management team had recognised that people’s needs were not being met. A comment beside the entry said ‘done now’ but was not dated. A social worker told us that the care service always respects people’s dignity and privacy based on the experience of one person they had worked with. Visitors told us that they thought their relative’s individual needs were met. Three GPs told us that people’s privacy and dignity is always respected and one said this was usually the case. We heard from staff that they were committed to caring for people until the end of their life. We saw that the temporary management team had recently requested training in this area of care from the local district nursing team, which has been confirmed by the team involved, who will be providing training in September 2009. Prior to this request, a concern had been raised in the service diary regarding end of life care, and a staff member told us that there was no clear system in place to help monitor the person’s well-being and no recording of aspects of care i.e. oral care. There is a form linked to end of life care in people’s files but this was not fully completed in any of the files and did not record if people had been asked about advance decisions. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 12,13,14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home have access to a range of activities, and are supported with day to day choices, and benefit from good quality meals. EVIDENCE: We looked to see how people’s social and recreational interests are supported by the home. The home employs an activities organiser for 12 hours each week. We were told that care workers also provide activities at other times. The activities organiser was on duty at the time of this inspection and we talked with them about how they planned the activities on offer each week. They explained how they used information about people’s interests in their care plans, and that they also made certain that they talked to each person individually each week. They completed records to show the activities each person had participated in, and also where people had declined to join in. We were told there is no timetable of regular group activities, although some activities such as minibus outings are usually advertised on the notice boards Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 18 around the home. We talked to the activities organiser about ensuring that people are aware what is taking place each day. On the day of this inspection a game of card bingo took place in one of the lounges and eight people joined in. Other popular activities include singing and musical entertainments, arts and crafts, and quizzes. The home has a stock of games and jigsaws, and the library service provides a selection of books (including audio books) that are regularly changed. The home has access to a minibus and during school holidays they arrange regular group outings. The home also has a smaller vehicle that is used to take smaller numbers of people out. A relative said that people living at the home would benefit from more trips out. The activities organiser also explained how she provides individual time for people who do not want to join in with group activities. The records we saw showed that she spent time sitting and chatting to some people, while some enjoyed being escorted for a walk in the gardens. Some people we talked to told us how much they enjoy sitting outside in the gardens during warmer weather. One person told us how they enjoyed going to the pub twice a week, which the service supports. On the day, of the inspection we saw that a meal was kept back for them once they had returned to the pub. We heard staff talking to them about their trip out and whether they had enjoyed it. Another person told us that they preferred their own company and that they only knew one person in the home, who had recently become ill. They said they did not wish to get to know other people at the home but appreciated staff spending time with them. We saw a member of staff sitting in the lounge chatting with a person who was knitting. A staff member from the management team told us that staff were being actively encouraged to spend time with people, which they said had not been common practice. A relative commented that the service could be improved by ‘more individual attention’. We did see one person who appeared to have been sat with people who struggled to make social conversation and respond to social cues, which left them isolated. We looked at how people’s religious and spiritual needs are met. We saw that in one person’s care plan that they had an ‘avid belief in Christianity’ but there was no plan as to how this need would be met. In another person’s care plan, it stated ‘church service’ but did not specify what type of service. We were told by staff that every Sunday a church service is held in the home and on Wednesdays a group of Gospel singers visit the home to provide entertainment. A social worker told us in their survey that the home always Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 19 responded to people’s diverse needs, which two GPs generally felt to be the case. We looked to see how people are supported to have choice within the home. Records do not show how it has been decided with each individual as to when they have a bath or if an alternative had been offered. We looked at two care plans that showed one person had moved rooms twice and one person has moved rooms three times but there was no clear record as to how or why this had happened. However, at lunch time we saw that people with dementia were shown a choice of drinks, including sherry, to help them make a decision. The same technique was also used for someone who the staff could not communicate directly with. This is good practice. Staff also employed the same approach with the pudding. After the meal, a staff member took time to gain people’s view on what they wanted to watch on television, while other people were seen choosing to sit in quieter lounges. People that we spoke to were positive about the food. Staff served people individually enabling them to choose the size of their portion. People were offered seconds and a sandwich was provided for someone who ate only a little of their hot dinner. They were also encouraged to have two portions of the pudding, which they appeared to enjoy, as staff said they were often reluctant to eat their main meal so needed to be encouraged. The pace in the dining room was unrushed, the staff were attentive, and during the meal the radio was turned down. The dining tables were attractively laid with tablecloths and matching serviettes, and a small vase of fresh flowers. We talked to the cook about the menus. She had only been employed as a cook for one week, although had previously worked as a care assistant. She showed us a record of her discussions with each person where she had found out their individual likes and dislikes, and suggestions for meals. She planned to adjust the menus in the near future to introduce some of the suggestions she had received. She also planned to incorporate seasonal foods and more local fresh fruit and vegetables, including a bowl of fresh fruit in the dining rooms. In the kitchen a wipe board displayed each person’s likes and dislikes and dietary needs. The cook said she goes around to see each person in the morning to find out what meals they wanted that day. A blackboard in the dining room showed the menu for the day including various alternatives such as salad, soup or sandwiches. We were told by the temporary management team that new menus will be in place in two weeks time and that staff are being encouraged to ensure that people’s personal preferences are recorded routinely. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 16 and 18. People using the 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 feel fully confident that their complaints and concerns will be dealt with appropriately. Staff are not all sufficiently aware of safeguarding issues to offer people consistent protection from abuse. EVIDENCE: A complaint has been made to the Customer Service Team at Devon County Council connected to poor care and poor practice, which we have been told will be investigated by a professional not linked to the home. We asked to see if there had been other complaints since the last inspection but no record could be found. Staff were unclear where this information would be kept. A person living at the home told us that they had complained about their bed, and was pleased that this had been replaced. However, they were unclear about who they had complained to and how they would make a complaint. Another person told us they felt safe, and talked to us about other institutions they had been in, where they had not felt confident. A staff member said that if people wanted to make a complaint they would advise them to put it in writing. Three relatives told us they knew how to make a complaint and two said the service always responded appropriately to any concerns they have raised and a third said this was usually the case. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 21 A safeguarding alert has been made to the safeguarding team at Devon County Council regarding concerns surrounding the quality of the care provided at the home. Devon County Council has replaced the previous management arrangements, and has put in post on a temporary basis an experienced manager and assistant manager, which they have confirmed in writing. However, there is currently no timescale attached to this arrangement. We found on one person’s file a disclaimer letter regarding a lost personal possession. It was unclear why this person had been made to sign a disclaimer and who had authorised the wording. If the person’s belongings had been logged appropriately on their admission the uncertainty around the alleged loss could have been resolved more easily. We spoke to care staff about their knowledge of their safeguarding role, they were clear about their role to report abusive practice, could give examples of what they considered abused, and one person that we spoke to was confident about who to contact externally if they needed to make an alert. We saw from staff records that safeguarding training has generally been provided. The temporary management team told us that they have reminded people of their whistle-blowing responsibilities if they have concerns about practice in the home as staff have acknowledged to them that things were wrong in the home but did not report their concerns outside of the home. We asked a staff member from the management team about their knowledge of deprivations of liberties and the Mental Capacity Act. They told us that they had attended training on the Mental Capacity Act several years ago but would not be able to apply this knowledge on a practical level. They were unable to speak in depth about possible deprivation of liberties and said they would like more training. A member of the temporary management team said that training was being provided in this area of care. However, an existing member of staff at Orchard Lea said that they were not aware of this course but said that they would like to go on it. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 generally provides people with a clean and homely place to live. EVIDENCE: Orchard Lea is a purpose built home and therefore has the advantage of level access on both floors, a large garden, a passenger lift, and a variety of communal and private spaces and several pieces of specialist equipment. However, there are areas where décor is torn i.e. communal toilets and many of the cupboards in the kitchen were old and in poor condition. We heard that there are plans to refurbish the kitchen in the near future. Staff told us that work has started to cracks in a bedroom, which we saw had been plastered. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 23 There is a large and pleasant bathroom with a modern accessible bath. There are several mobile hoists around the home, but we were told by staff that currently nobody living at the home needs to use the hoist. One person told us that they knew how to contact staff using a call bell, although they said they did not need to use it as the staff checked on them regularly. However, people in the dining room on the first floor of the building did not have a call bell and said they would have to wait for someone to come. Most of the bedrooms are small by current standards and this affects the amount of furnishings and fittings that can be accommodated. Therefore there is not enough space to provide comfortable seating for two people, and a table to sit at. Rooms are clean and odour free. Some appeared homely and personalised but generally fittings are dated and tired in appearance. Some of the bedroom furniture is utility in style and marked, such as the fitted wardrobes and sink units. Where possible efforts have been made to brighten rooms with colourful curtains. There are no current plans to refurbish the bedrooms. People were positive about their bedrooms, despite their lack of size, particularly as they had been able to bring in a few things to make their room more homely. One person told us that their new bed was very comfortable, and another person who had a larger room said they were happy with the size of it. We saw that a number of beds had been bought for the home; with some being kept in storage. We visited twenty two bedrooms during the visit and saw that the home is kept clean and odour free, apart from one room where there was an underlying unpleasant odour. Staff were clear about infection control and could give us examples of good practice. One staff member told us that the standards of cleanliness had been raised by the temporary management team, and that one vacant room had been cleaned three times before they were satisfied, which they viewed as a positive approach. All bathrooms and bedrooms have soap and paper towels, and signs instruct staff to keep bathrooms clean. One laundry room was outside the home. We were told that this room was used less often than the laundry inside the home, although provided useful additional facilities when extra machines were needed. We heard that this room is sometimes used for washing laundry for people who have infections. We heard that all items to be washed are placed into specially designed red bags that dissolve in the washing machine. These bags reduce the chance of cross contamination and we saw these bags being used in some people’s rooms. However, we found the outside laundry room was in poor state of repair and the floors were dusty. This may compromise the safety and cleanliness of the laundry and may increase the chance of cross contamination. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 27,28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have a caring approach with recognition of individual needs. Training is generally up to date but some staff require further updates in order to translate their knowledge into practice in order to benefit the people living at the home. EVIDENCE: The rota showed us that generally five care staff are on duty in the morning, three in the afternoon and three in the evening, with two on duty at night. They are supported by an assistant manager, and domestic staff overseen by a home’s manager. We were told that the home no longer uses agency staff. There is a stable core staff team, many having worked at the home for a number of years. The staff we talked to clearly enjoy their work and took a pride in providing a good quality of care and services. They told us that it was important to know the individual needs of the people they care for, and this was demonstrated in discussion and observation but was not backed up by care records. Staff recognised the importance of building up a relationship with visitors, and this was apparent from our observations on the day of the inspection. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 25 The six people we talked to in depth praised the care staff highly and told us the care workers helped them in exactly the way they wanted. They told us the staffing levels were good and that there were always enough staff to help them at whatever time of the day they wanted assistance. Relatives told us that staff always have the right skills and experience to look after people properly. They said ‘caring for our mother – what we have seen is excellent’. A second relative told us that the ‘standard of care is good’ and ‘staff – excellent’ and a third said staff were ‘caring’. Two people felt that their relative usually received the support to live they life they choose and one person said their relative always did. We have been told that staff from the home no longer provide night time cover to the bungalows situated next to the home, and we saw an entry in the home’s diary to confirm that day time cover has now been transferred to a central call centre on 31st May 2009, which addresses a concern that we raised at the last inspection. We looked at the staff recruitment files and found that no new staff had been employed since the last inspection; therefore we were unable to check that the home had met a previous requirement on safe recruitment procedures. We have not been provided with the NVQ levels of staff at the home. We looked to see how staff were supported to do their jobs. We saw copies of certificates of training courses attended in the last year by staff. These included food hygiene, moving and handling, care of medicines, first aid, and conflict resolution. One of the management team has responsibility for staff training and keeps a record of when staff are due for updates and refresher training. Generally, staff are provided with updates in a timely manner. We also saw that a number of staff have been provided with dementia awareness training and that seven staff members are undertaking a distance learning course to update their practice. However, this tends to be people at a more senior level at the home, who from observation spend less time with people with dementia than other staff members who have regular contact. From the information that has been provided to the Commission, it showed that the majority of staff involved with medication at the home have received recent medication training but we were told that people’s skills were going to reviewed given the problems with medication management and administration in the home. We saw from the home’s diary that training needs had been identified for some staff teams i.e. risk assessments, and that some people had been reminded of their responsibilities i.e. care planning and medication duties. We also saw in the diary that care staff have been reminded to attend handovers at the beginning of their shift and we saw this happen on the day of our inspection. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at standards 31,32,33,35,36,37 and 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Orchard Lea are placed at risk by a lack of permanent leadership, poor recording and notification of concerns, and poor financial management. EVIDENCE: The home has not had a registered manager for over two years despite requests from the Commission for this to be resolved to help provide suitable leadership and stability for the home. Staff told us that they have struggled because of a lack of leadership and structure, which meant for one person that staff did not work in a productive way. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 27 We spoke to staff who were positive about the temporary management arrangements, and who felt this was what the home needed, as in one person’s words standards had dropped while for another staff member they said that they now felt listened to. One person said that the staff team were ‘being kept on their toes’ in order to raise standards. There has been no formal confirmation of how long the temporary arrangements will be in place. We could see that where the temporary management team have identified problems that they have addressed them i.e. poor practice. However, as there are significant problems at the home i.e. care planning, monitoring of health and welfare, as well as medication practice, their task is considerable. We looked to see how people can influence the way the home is run and how they are supported to share their views. We were told that every three months a Residents’ Meeting is held in the home, chaired by an advocate from Age Concern. Activities and outings are regularly discussed in these meetings, along with other topics relating to daily life in the home. However, we were told that there are currently no their systems in place for people visiting, working at and living at the home to share their views i.e. annual surveys, regular staff meetings and supervision. We looked at the way the home looks after money and valuables handed to them for safe keeping by people who do not want to (or who are unable to) look after their own cash or valuables. (See also Complaints and Protection) Individual records have been kept for each transaction. The money is held in a bank account set up by Devon County Council specifically for people living at the home. A float is kept in the home – this provides sufficient cash for daily requirements, although larger sums would need to be requested in advance. We looked at a random selection of the records. One record showed an error in the balance calculation. We were assured that most transactions are doublechecked by a second member of staff to ensure the balances are correct but in this instance only one member of staff had dealt with the transaction. We were reassured to hear that Devon County Council regularly audits the records of cash held by the home on behalf of people living there, and there audits were likely to discover any errors in calculation. We saw in the care plan of a person that had stayed at the home for a respite stay that the following had been recorded ‘envelope containing monies counted with client, assistant manager and care staff’ but there were no names or dates. We saw a deposit for a building society that was for a large amount of money but it was not clear if this was the same amount of money that had been counted or who had paid it into the building society or how this decision had been made. Staff told us that there had been a lack of supervision. We also looked at records of staff meetings and one to one supervision. No staff meetings or Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 28 supervision were recorded for the year 2008/09 until recent weeks. In the last month a staff meeting and a manager’s meeting had been held and further meetings were planned in the next few days following this inspection. No records were available of staff supervision for 2008/09 although one manager said she had started to arrange supervision sessions for the near future. We were told that there have been a number of staff off sick and that this had not been monitored properly and that staff had not received the support required on their return i.e. ‘back to work’ meetings. The quality of records in the home i.e. care planning, finance management medication management is poor. We were directed towards a staff member’s individual box of personal belongings to find the file relating to a person who had previously stayed at the home, rather than it being stored appropriately. Significant information is not dated so it is hard to make a judgement whether it is current and relevant. As part of the inspection, we look to see if the home has reported significant incidents at the home i.e. serious accidents such as an injury that resulted in a hospital admission. However, we could see from accident records, daily records and talking to staff that we had not been informed appropriately. For example, someone had fallen resulting in a fracture and hospital admission. This lack of information means that we could not monitor how the home dealt with increasing risk or whether they responded in a timely manner when someone was injured. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 1 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 2 2 2 2 Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (2) (a) Requirement Timescale for action 31/07/09 2 OP4 3 OP7 4 OP8 Assessments must be kept under review to ensure that people’s changing needs are recognised i.e. emotional needs. 18 (1) (c ) People’s needs must be met by (i) staff who have received training appropriate to the work they are to perform. 15 Each person must have a current care plan. Each person’s care plan must describe in detail the person’s needs, personal preferences and provide clear guidance as to how these changing needs are to be met. This is so that staff and people using the service know how each person’s changing needs will be met. 12 Arrangements must be put in place to promote and provide for the health and welfare of people using the service. In particular this refers to nutritional monitoring including weight loss, end of life care, falls management and pressure area monitoring and management. This is so that people remain DS0000039280.V375749.R01.S.doc 31/08/09 31/08/09 31/07/09 Orchard Lea Version 5.2 Page 31 5 OP9 13 (2) 6 OP9 13(2) 7 OP9 13(2) 8 9 OP16 OP29 17 (2) Schedule 4 19 (1) (a) (b) Schedule 2 healthy and any changes can be identified rapidly and appropriate action taken in a timely way. Arrangements must be made for the safe custody of controlled drugs in the home. This is to prevent the risk of diversion of these occurring. An immediate requirement for this was issued 12/06/2009 Arrangements must be made to ensure that medicines are available to be administered as prescribed. This is to ensure that people receive their medicines as prescribed to receive maximum benefit from them. Arrangements must be made to ensure that when medicines are prescribed with a variable dose that the actual dose administered is recorded. This is so that the response of a person to a medicine can be monitored and referred back to the prescriber if needed. A record of all complaints must be kept and the action taken. Staff must have a full employment history, two written references, including one from their last care position, proof of identity and POVA/CRB checks before working at Orchard Lea to help protect the people living there. (Previous timescales of 31/05/07 and 31/12/07 not met). This requirement could not be inspected as staff told us that no new staff had been recruited. There must be a quality assurance system in place which is reviewed at regular intervals to ensure that people can DS0000039280.V375749.R01.S.doc 15/06/09 12/07/09 12/07/09 12/07/09 31/07/09 10 OP33 24 (1) (a)(b) 31/08/09 Orchard Lea Version 5.2 Page 32 12 OP35 16 (2) (l) 13 OP36 18 (2) 14 OP37 17 (3) (a) 15 OP38 37 influence the service and promote good standards. A robust system must be in place so that people feel confident that their money and valuables are kept safe. Staff working at the home must be appropriately supervised to ensure that standards are maintained and people are cared for appropriately. Records must be kept up to date and be dated i.e. care plans, medication records and money/valuables. The Registered Person must ensure that events adverse to the welfare of people using the service are reported to the Commission in accordance with regulation and guidance. This is to enable monitoring of any patterns of adverse events or how the home is managed. 31/07/09 31/08/09 31/07/09 12/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP4 OP7 OP8 OP8 OP9 Good Practice Recommendations People’s communication needs must be addressed with a plan of action before they move to the home. Care plans should show how people and/or their representatives have been involved and be kept under review. There should be a consistent system in place to measure people’s food intake to help monitor their well-being with a clear action plan to address concerns. Weights should be recorded regularly with a clear action plan to address concerns i.e. weight loss. It is recommended that agreement is reached with visiting healthcare professionals about the recording of medicines DS0000039280.V375749.R01.S.doc Version 5.2 Page 33 Orchard Lea 6 7 8 OP9 OP10 OP11 9 10 11 OP12 OP18 OP24 12 13 OP30 OP31 administered by them. It is recommended that the temperature of the medicines room be monitored so that appropriate action can be taken if it is found to be high. People should have access to regular baths at their chosen time to help maintain their dignity. Staff should be provided with clear guidance to meet the needs of people reaching the end of their life. Care plans should reflect people’s advanced decisions and preferences. Care plans should describe how people’s identified spiritual needs will be met. Staff should be provided with appropriate training to help safeguard the people in their care. Bedrooms should contain comfortable seating for two people; at least two accessible double electric sockets and a table to sit at to make them a more comfortable place to spend time. There should be a recorded improvement plan to ensure that that all staff are competent to carry out their individual role to protect the people living at the home. The home should have a manager registered with CQC to help ensure they are competent for this role and to provide clear leadership for the home. CQC should be informed if the home is running without a manager for over 28 days. Orchard Lea DS0000039280.V375749.R01.S.doc Version 5.2 Page 34 Care Quality Commission South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: 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. 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