Inspection on 15/09/09 for Park Hills Nursing Home

This inspection was carried out on 15th 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park Hills Nursing Home 17/05/10

Park Hills Nursing Home 03/02/10

Park Hills Nursing Home 15/12/09

Park Hills Nursing Home 19/10/09

Park Hills Nursing Home 30/04/07

Park Hills Nursing Home 31/01/06

Park Hills Nursing Home 21/07/05

Park Hills Nursing Home 01/02/05

Park Hills Nursing Home 09/08/04

Park Hills Nursing Home 03/06/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Park Hills Nursing Home 199 Chamber Road Oldham Lancashire OL8 4DJ     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: Helen Dempster     Date: 1 6 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 36 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 36 Information about the care home Name of care home: Address: Park Hills Nursing Home 199 Chamber Road Oldham Lancashire OL8 4DJ 01616246671 F/P01616246671 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ms Barbara Rogers care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical disability - Code PD The maximum number of service users who can be accommodated is: 17 Date of last inspection Brief description of the care home Park Hills Nursing Home provides 24 hour nursing care and accommodation for up to 17 people over the age of 65 years. Mrs Barbara Rogers is the registered owner and manager of the home. The home is situated approximately one mile from Oldham town centre and is reasonably close to local amenities such as shops, pubs and local schools. Bus services are also available close by. The home is a Victorian property that has been extended at Care Homes for Older People Page 4 of 36 Over 65 17 0 0 17 Brief description of the care home the rear. Entrance to the home is by a purpose built ramp at the side of the building. Well-maintained gardens are available outside the property. The home provides 17 single bedrooms, on both the ground and first floor and the majority of these are south facing. A passenger lift and other aids, such as hoists are available. There are three bathrooms. On the ground floor there is a choice of a large lounge/dining room or a smaller quiet lounge. A copy of the homes last inspection report was available from the main entrance area of the home. The weekly fees ranged from £445.65 to £490.00 dependent on the package of care required. Further details regarding fees and other information about the home are available from the manager. No additional charges are currently made. Care Homes for Older People Page 5 of 36 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 key unannounced inspection included a site visit. The manager and staff at the service did not know that the visit was going to take place. In April 2009 an Annual Service Review (ASR) was done, as part of the lead up to this inspection. This involved the administrator/deputy manager filling in an annual quality assurance assessment (AQAA), and people who use the service and staff filling in surveys to tell us their views of the service. We then considered this information, and all the other information we had received about the service, so that we could decide when we needed to visit the service to do a key inspection. The outcomes for people who used the service at the time of the previous Key Inspection were excellent. However, some of the information we received when we completed the ASR suggested that things had changed. Therefore, we decided to change our inspection plan and to bring forward the next key inspection. Prior to this inspection, we sent surveys out again to people who use the service and staff so they could tell us what they thought about the service. We did not receive any completed surveys from people who use the service or staff. Care Homes for Older People Page 6 of 36 All of the key inspection standards were assessed at the site visit and information was taken from various sources. This included observing care practices, talking with people who use the service, the staff, the manager and the administrator/deputy manager. Three people were looked at in detail to learn about their experience of the service from when they first used it to the present-day. A selection of records were looked at, including medication records, training records and care records. We use the terms, we, and, us, throughout this report when we are referring to the Care Quality Commission. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: We provided the manager with detailed feedback at the time of the visits about all the things that needed to improve. These included the following: The manager needed to make sure that wherever possible, an assessment of needs is completed for each individual before admission to make sure that the service could meet each persons needs. Care plans, risk assessments, nursing and wound treatment plans, moving and handling assessments and other care planning records needed to provide specific information about each individuals needs and clear guidance to staff as to how to meet these needs. All these care plan documents also needed to be regularly reviewed and updated to take account of changing needs and the advice of health care professionals. All equipment used, including pressure relieving mattresses, needed to be correctly set up, checked and monitored to make sure that it was working properly and was serving its purpose to protect people from harm. Peoples nutritional needs need to be regularly reviewed and updated. This included noting their preferred diet and ensuring that people who had lost weight, with implications for their health, were promptly referred to a dietician for expert advice. There needed to be a clear audit trail to demonstrate that care was always given appropriately. The manager needed to review staffing levels in the light of the dependency levels of people using the service, the layout of the building, the number of people nursed in bed, and some peoples comments about how, busy, the staff were. Such comments included, sometimes you ring the bell and you have to wait, and, sometimes theyre busy, very busy, you see theyve got to feed a lot of people here. Menus needed to be reviewed to include planned alternative choices. Care Homes for Older People Page 8 of 36 Peoples individual needs concerning activities needed to be assessed and documented and the range of activities extended to meet individual need. The complaints procedure needed to be reviewed to make it more user-friendly for people. Records of the outcomes of all complaints should be held. All staff needed to have training in the protection of vulnerable adults in order that people were always safeguarded from harm. The recruitment procedure needed to be robust enough to safeguard people. This included obtaining appropriate and timely Criminal Records Bureau (CRB) checks. There needed to be a more proactive approach to assessing staff training needs and planning training accordingly. Staff should also be provided with regular supervision and monitoring of their practice. The manager needed to make sure that we are informed of all issues that have implications for people receiving the service in line with legislation. The lines of accountability at the home needed clarity, and the manager needed to be seen to be involved in the completion of the AQAA and records held at the home. This is necessary in order that the manager could ensure that people received an appropriate service and to monitor practice and make improvements. The outcomes of quality assurance audits should be collated so that the views of people could be incorporated into planned improvements. Fire safety at the service must meet the standards of the local fire department, in order that people are protected from the risk of fire. 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 36 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 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not consistently assessing peoples needs prior to moving into the home meant that they were not always assured that their needs could be met. Evidence: In the AQAA the administrator/ deputy manager made reference to, the thoroughly, methodical way we do our assessments before we admit the individual, then again once they have been admitted to make sure that every need is being met and that it is person centred. To find out whether this was the case, we looked at a range of documents and we looked carefully at the care provided to three people from the point of their admission to the present time. We also talked to people using the service and staff. In each persons care file a form had been completed called a, long term needs assessment, but we saw that all of these were either undated, or written on, or after, Care Homes for Older People Page 11 of 36 Evidence: the date the person had been admitted to the home. We were told that many people were admitted to the home as an emergency, which meant there was limited time to undertake assessments before they arrived. In these instances, the manager said that information was obtained by telephone and fax and staff continued with their own assessments over the following days and weeks, as they got to know the person. We were told that where people were not admitted as emergencies, the manager visited them prior to admission and carried out a pre admission assessment. The manager said that she recorded the information on the long term needs assessment form, but we did not see any examples of these forms which had been completed prior to a persons admission. It was recommended that a separate form be developed specifically for recording the outcome of pre admission assessments, so that any information obtained prior to admission was clearly recorded at the time of the assessment visit and could be used to determine whether the persons needs could be met at the home. Care Homes for Older People Page 12 of 36 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were met with respect for their privacy and dignity, but failure to always assess, meet and review peoples needs, including health care needs, put them at risk. Evidence: In the AQAA the administrator/ deputy manager stated, all the service users are treated with respect, dignity, consulted on matters to do with their care, views, and this is taken seriously. Reference was also made in the AQAA to having, up to date care plans. To find out whether this was the case, we looked at a range of documents and we looked carefully at the care provided to three people from the point of their admission to the present time. We also talked to people using the servic, the manager and staff. In each of the three care files that we saw, care plans and risk assessments were provided, but we found a number of problems with how peoples personal care and health needs were recorded and monitored. Care Homes for Older People Page 13 of 36 Evidence: Care plans were quite generalised and did not provide enough specific information about each person as an individual. For example, there was little information about peoples preferred daily routines and abilities, or how staff could help them exercise choice. Care plans were not reviewed monthly and did not always contain accurate information about the care actually needed by people. We saw from letters kept in peoples files that they had been seen by other health care professionals, such as the dietician and the tissue viability nurse, but any advice or instructions given had not been used to update the care plans. This meant that to get the most up to date information about the care actually needed by the person, staff would have to read through the whole file. Care plans should be used as a daily working tool, providing all the information necessary to inform staff how they should be delivering care to each person. Risk assessments were also not reviewed monthly, and in some cases they were inaccurate. For example, one person did not have a moving and handling assessment. In addition, for another person the information contained in the assessment was not detailed enough, as it only said that two carers were needed to transfer them, but did not give any information about equipment needed such as hoists. None of the three people we looked at had bed rail assessments in their file, although we saw that they all had bed rails on their beds. Several people had pressure ulcers and wounds that required dressing. Detailed wound assessment charts and care plans were not available for any of them, although the tissue viability nurse had seen them and left instructions about their treatment. In the daily records for each person, staff had written that dressings had been changed, but there was little indication as to whether the wounds were improving or deteriorating, and there were no up to date photographs of the wounds for staff to use to evaluate progress. All three people were being nursed on pressure relieving mattresses, but for two of them the pressure mattresses had been set at the wrong pressure for their weight. This meant that the equipment may not work effectively and they may have been at risk of getting more pressure damage. Care plans should contain information for staff about what equipment is being used and how it should be set up and staff should check the equipment very regularly to make sure it is set as it should be and is working properly. The care plans for all the people we looked at said they were mainly nursed in bed and needed to be regularly repositioned to prevent pressure ulcers. Care plans also told Care Homes for Older People Page 14 of 36 Evidence: staff to record each persons fluid intake and output and dietary input. We looked at the charts for each person and saw that the fluid charts were maintained quite well but the, turn, charts often showed a period from early afternoon to early evening where staff had not recorded if the persons position had been changed. We could not tell if this meant people were not being moved in the afternoon, or they were, but staff were not recording it. We had concerns about how peoples nutritional needs were being monitored and acted on. Nutritional Risk Assessments and Malnutrition Universal Screening Tool (MUST) scores were either not completed, or had not been reviewed on a regular basis. Although the manager did say people were weighed each month, the records showed gaps of several months where weights were not recorded. Where people had lost weight, it was not clear what action had been taken to address this and care plans had not been amended to reflect the change to the persons condition. It had been identified that one person had lost weight, and they did have a MUST assessment that said they should be weighed weekly, but the last weight recorded was 20/8/09, when we saw that they had lost more weight since the previous time they were weighed. Another problem we saw in records of peoples weights, was that weights were recorded in a mixture of imperial and metric measurements. This made it more difficult for staff to compare previous weights and see if the persons weight was stable or they were actually losing weight. Given that these people already had low body weights, and significant pressure damage, then nutrition and weight is something that needs to be very carefully monitored to safeguard them and the outcomes recorded. We were very concerned that this wasnt always the case. Despite all the inconsistencies in the record keeping, all the people we saw looked well cared for and comfortable and all the interactions between staff and people using the service were seen to be kind, gentle, considerate and respectful of their privacy and dignity. The people we spoke to said that the staff were very good. Comments included that they were, right decent girls, they will do anything you ask - nothing is too much trouble, and, I cant ask for anything better. However, the lack of detail in care plans and the erratic method of evaluating and reviewing risk assessments and care plans did mean that people were at risk of not having their health care needs identified or met in a timely manner. There was also a lack of an audit trail to evidence that care was always given appropriately. There were some comments about how, busy, the staff were. One person said, sometimes you ring the bell and you have to wait, and added, sometimes theyre busy, very busy, you see, theyve got to feed a lot of people here. We did discuss these comments with the manager in the context of whether staffing levels were Care Homes for Older People Page 15 of 36 Evidence: sufficient to meet the needs of people who had high dependency levels. (See Staffing for details). We looked at the way that medication was stored and how people were supported to take their medication. We were told that all 17 people who use the service take prescribed medication. Non-prescribed medication which took the form of, homely remedies, were in use and there was no policy statement concerning the use of this medication. It was recommended that a policy was put in place. We saw that some medication was dispensed from a monitored dosage system and some was dispensed from bottles. We saw that records of the receipt and disposal of medication were held and that records of controlled drugs that we sampled were accurate. We asked a nurse about whether their practice when giving out medication was ever observed and monitored. The nurse said that they dont have any assessment of practice, as there is only one trained nurse on duty at any one time. When asked about training in medication practice, one nurse said, weve not had medication training for some time. This nurse explained that the last time that they personally had received medication training was when they completed their, back to nursing, course some years ago. We were concerned about the lack of assessment and monitoring of nurses practice concerning medication and the fact that although some training in medication practice was planned for some staff, most of the staff had not had such training for many years. We advised the manager that as the home had not received a pharmacy inspection for some time, and that there were some issues about not having recent training, and also dressings practice, we would make a referral for the Care Quality Commission Pharmacist Inspector to visit the home. Care Homes for Older People Page 16 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefited from their friends and relatives being made welcome at the home, but limited activities meant that they did not always have their social needs met. Evidence: In the AQAA the administrator/ deputy manager stated, we provide excellent meals with both choice and flexibility. We have built up excellent relationships with service users, relatives and the various professionals. We encourage service users to be in control of their own lives as far as possible. To find out whether this was the case, we talked to people, the manager and staff, saw meals being served and looked at the programme of activities. We saw that there was open visiting arrangements at the home and that people were made welcome. This is good, as it allows people to maintain good relationships with their family and friends. One of the peoples files contained their, life story. This had been written by the persons relatives, and provided vital information about what was, and is, important to this person. We did not see this type of information on the other two files we looked at, which contained very limited information about these peoples social needs. One Care Homes for Older People Page 17 of 36 Evidence: example was a reference on one persons file to, use of time, where it was noted that, staff to offer involvement with organised activities, although (this person) declines this. One person talked about being, bored, and added that they had, never been out of the room, while theyd been at the home. In addition, we saw no documented evidence of organised activities and we saw that written information about the home noted that they dont provide traditional activities due to the dependency level of people. When we discussed this with the manager, she said that nail care, aromatherapy, playing music, certain radio channels, television, massage and relaxation were provided. It was recommended that the, life story, and social needs of all individuals is always recorded and that the range of activities is increased to meet individual need. The service operates a four week rotating menu. We were told that only five of the 17 people receiving the service were able to have a normal diet. The remaining people had a liquidised/soft diet. We saw that planned alternative choices were not available on the menu. However, the administrator/deputy manager and the cook told us that if people did not like what was being served, an alternative was provided. When looking at care plans, we saw that peoples likes and dislikes concerning food were not always recorded. It was recommended that this information is recorded to enable people to enjoy their favourite foods. Care Homes for Older People Page 18 of 36 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of appropriate policies, procedures, robust staff recruitment and staff training meant that people were not always safeguarded from abuse. Evidence: In the AQAA the administrator/ deputy manager stated, all staff are made aware of POVA (the protection of vulnerable adults), no secrets policy, signs and symptoms of abuse, plus whistleblowing. To see if this was the case, we looked at policies, procedures and records and talked to people, the manager and the staff. We saw that a copy of the complaints procedure was displayed in each persons room. The complaints procedure was quite formal and not user-friendly. Stage two of the procedure stated the need to, submit a formal written grievance within 10 days. It was advised that some of the people using the service may not be able to do this and that the procedure would benefit from review to address this and to include the details of Oldham Council, the Ombudsman and the Care Quality Commission. The administrator/deputy manager said they had not had a complaint in the last four years and we saw that no record of complaints and their outcomes was in place. A copy of Oldham Councils Protection of Vulnerable Adults Policy was not readily available at the time of the visit. The administrator/deputy manager said that training in the protection of vulnerable adults (POVA) is covered in the, Skills for Care Care Homes for Older People Page 19 of 36 Evidence: induction programme. However, there was no evidence to demonstrate that staff had received this training. The administrator/deputy manager said that the last POVA training had been delivered in early 2007, but there was no audit trail to demonstrate this. It was of concern that the only audit trail of any discussion with staff concerning POVA was a sheet of paper which the administrator stated was used for staff on induction. We saw that this information was limited to a list of basic questions concerning the protection of vulnerable adults and that there was no evidence to demonstrate that this discussion had taken place with any of the staff, as there was no records of any answers to these questions. Therefore, in the absence of training in POVA, there was no evidence to demonstrate staff understanding of this process. The manager was advised to phone Oldham Councils Safeguarding Adults Team to arrange training for all staff, including the manager, as a matter of urgency. The administrator/deputy manager had requested this training by the second day of the inspection visit. Just prior to the inspection, we had attended a safeguarding adults meeting following a referral made by a tissue viability nurse concerning pressure care and moving and handling arrangements for three of the people who lived at the home. There was evidence to demonstrate that the manager was cooperating with this process and that the administrator had put in place some of the necessary actions. We were concerned that not having robust recruitment procedures meant that people were not always protected from the potential for poor practice and abuse. (See Staffing for details). Care Homes for Older People Page 20 of 36 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. People benefited from a warm, clean, maintained environment, but fire safety practice does not always protect people. Evidence: In the AQAA the administrator/ deputy manager stated, we provide a safe, well maintained environment both within the home and home grounds. We comply with requirements from the local fire service. To see if this was the case we looked around the home, looked at records, including fire safety records, and we talked to people, the manager, and the staff. We saw that the home was warm and cosy and people we spoke to were happy with the environment. One person told us that they, love, their room. We saw that peoples rooms had lots of personal effects, including photographs, and were comfortable and homely. We saw a range of risk assessments concerning the premises. However, many took place on 18/10/06 and were in need of review. The administrator/deputy manager told us that they keep a record of all maintenance issues. The need to repair the base of one bath hoist was discussed and this repair had already been arranged. Care Homes for Older People Page 21 of 36 Evidence: We had some concerns about fire safety records. (See Management and Administration for details). We also observed that wedges were being used to hold open some doors, including bedroom doors, the laundry, a bathroom and the upstairs sluice. This practice must cease as it puts people at risk from fire. Care Homes for Older People Page 22 of 36 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. People who use the service benefit from support provided by caring and committed staff. However recruitment practice was not robust enough to protect people and inconsistent staff training and development impacted on care practice. Evidence: In the AQAA the administrator/ deputy manager stated, we have the correct number of staff with the appropriate mixed skills. We promote training with all staff. To see if this was the case we looked at staff files, training records and the recruitment procedure and we talked to people, the manager, and the staff. We looked at the recruitment files for the two most recently recruited staff. These files were disorganised and it was quite difficult to find information. One of these staff had commenced employment in June 2008, yet the Criminal Records Bureau (CRB) check on file was dated 16/03/09. There was no CRB on file for the other member of staff who had commenced employment in May 2009. We asked whether a POVA First Check had been made for both these people before they commenced work. Neither the manager or the administrator/deputy manager were aware of the need to obtain a POVA First Check. Consequently, both these people had been working unsupervised with vulnerable people without appropriate and timely checks being made. Due to the potential of risk to people we issued an immediate requirement about this issue and the administrator/deputy manager wrote to us following the inspection visit to confirm Care Homes for Older People Page 23 of 36 Evidence: that it had been addressed. Other aspects of the recruitment procedure also concerned us. In particular, the two application forms we saw were not fully completed and one was almost blank. There were also gaps in the employment histories which had not been verified and appropriate references had not been taken. The only reference on file for a newly recruited nurse was from an ex colleague who was a daycare assistance who had worked with this employee eight years previously, before this person qualified as a nurse. Therefore, there was no reference from the most recent employer and no reference concerning this persons practice as a registered nurse. For the other person, the only reference related to previous employment in a non-care setting from 1989 to 2007. This reference was incomplete and there was no reference from the most recent employer. This meant that there was no reference for this person that related to their suitability for the carers role. We looked at copies of the most recent staffing rotas. We saw that minimum staffing levels were one nurse on duty at all times, with two carers. At busy times, including the morning, the nurse was supported by three carers. When on duty, the manager was the nurse on duty on the rota, so her hours were not in addition to these minimum levels. Ancillary staff included two domestics between 8am and 1pm. The administrator/deputy manager worked on a full-time basis. We were concerned that the manager had based staffing levels on local authority guidance which dated back many years. We asked whether staffing levels had been reviewed/updated in the light of the dependency levels of the people using the service. The manager said that she had put an extra carer on the morning shift some time ago as she realised that this was needed. She added that she was following the guidance given by the local authority. We asked the manager whether she had ever accessed up-to-date information and guidance from our website or other sources concerning basing staffing levels on the dependency levels of people using the service. She replied that she had not. We concluded that due to the high dependency levels of people using the service, especially the fact that most of the 17 people were being nursed in bed, five of the 17 people needed help to eat on a one-to-one basis and many of the people needed to be turned regularly to maintain pressure care, a full review of staffing levels needed to be conducted to ensure that peoples needs were met. We saw that training certificates for staff were held in their personal files. There was no formal training audit to enable training needs of the staff team to be assessed and met. Following advice from us, the administrator/deputy manager devised a training audit during the course of the inspection visits. We saw that staff training in many areas was in need of updating, It was of particular concern that staff had not receive Care Homes for Older People Page 24 of 36 Evidence: training in care of people with dementia, as most of the people using the service had dementia. We saw that staff had not been offered one-to-one supervision to enable their training needs to be assessed. In addition, staff meetings were not being held so that training and development needs might be discussed. Overall, it was seen that as there had been no mechanisms to assess, plan and priorise staff training needs, training had been largely reactive rather than proactive. One example was that following a visit by the tissue viability nurse, in response to the concerns this professional raised, the administrator/deputy manager arranged training for staff in palliative care, health and safety, moving and handling, and ageing skin. It is commendable that this training was arranged without delay. However, the need for a more proactive approach to planning training was discussed to ensure that staff training and development needs were always addressed. The administrator/deputy manager showed us a copy of the in-house induction procedure, the Skills for Care induction procedure and the staff handbook. We saw an example of a completed in-house induction which had been completed on the first day of employment and had lasted only one day. We did not see any completed work books for the Skills for Care induction process. We observed staff caring for people. We saw that they were gentle, caring and respectful of peoples needs. We also spoke to staff about staff training and staffing levels. One nurse told us that they believed that it was a registered nurses personal responsibility to ensure that their training needs were updated. We spoke to another member of staff who was helping somebody to eat their meal. This member of staff said that they had enough staff and added, I dont have any problem at all. People who use the service did talk about staff being, busy, and were aware of the tasks they needed to complete. One person said of the staff, theyre very good, I cant moan about any of them, and added, they always come and look at you. But this person also talked about staff sometimes being too busy to talk to you and added, they do come in, but theyre busy. Care Homes for Older People Page 25 of 36 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. This service was not always run in the best interests of people who live there and their safety and welfare were not always promoted. Evidence: In the AQAA the administrator/ deputy manager stated that what the service does well is, good teamwork and leadership, staff training and adhering and complying with relevant legislation. To see if this was the case we looked at records and spoke to people, the manager and staff. We have had very little communication from the home since the last inspection. We discussed the fact that we had not received reports about issues that the service should have informed us of in line with legislation. (We call these Regulation 37 reports). When talking to the manager, it was evident that she was unsure of which issues should be reported to us. When we asked the manager whether she was aware that reports should be sent to us about pressure sores of grade 2 or above, the manager agreed that we should have been notified of these issues, but had not. The Care Homes for Older People Page 26 of 36 Evidence: manager/proprietor of the home said that she had a period of absence from May 2009 until August 2009. She agreed that she had not informed us of this and was not aware of the need to do so. We were also not advised of the arrangements for management of the home in the managers absence. While present at a safeguarding strategy meeting, Oldham Council contracting officers informed us, that when looking at recruitment files they had found references to disciplinaries of staff and other matters. We had not been informed of these issues by the manager. As noted earlier, the administrator/deputy manager had completed the AQAA. We asked the manager about the role of the administrator and about the lines of accountability at the service. The manager stated that the administrator, does a lot of the paperwork. We saw that the paperwork that the administrator/deputy manager did complete included care planning, reviews of care etc. When we asked the manager about her input into care planning and reviews of care, she said, we go through them together, she just writes them. The manager stated that the administrator was not a registered nurse and stressed that she was, not a trained member of staff. However, the manager talked about the administrator acting as a deputy manager, so there was some confusion about this persons role. When the administrator/deputy manager was asked if they had a job description they responded, not really. We asked the manager to provide evidence to demonstrate ongoing update of training and development. The manager was unable to produce this record. We stressed that was important for the manager to undertake periodic training and development, to maintain and update their knowledge, skills and competence while managing the home. Overall, there was no documented evidence of monitoring of practice by the manager, as there were no staff meetings and no formal supervision of staff. The manager said that she worked alongside the staff, but we saw no evidence to demonstrate assessments of staff practice, including when administering medication. We were concerned about the fact that the completed AQAA made constant reference to things being done, and assessments and other records being completed, when we did not find this always to be the case. Examples included a statement to the effect that the service would, continue with our staff development programme and the competence and professionalism of all staff. Yet, the section of the AQAA concerning complaints and protection notes that what the service could do better was to, make sure all staff receive adequate training. It was of concern that in the context of Care Homes for Older People Page 27 of 36 Evidence: protection, the AQAA noted that one example of evidence to show that the service does things well was, the evidence is when you get a service user being admitted with pressure sores and how these are looked after and cleared up. In addition, when describing plans for improvements, there was also references to, continue as we are, and, I cannot think of anything at this present time what we could do better. However, we are open to suggestions that would improve any of our services. This tells us that the management of the home was open to ideas for improvement, but was unaware of the degree to which the quality of the service had deteriorated since our last inspection of the service. The manager said that all fees are paid by standing order for all the people using the service and that the homes policy is not to hold money on behalf of people. The administrator/deputy manager said if a resident wants something, the item is purchased from petty cash and the persons relatives are billed for the item. The administrator/deputy manager said that they hand out questionnaires to relatives throughout the year to obtain information for quality assurance purposes. Examples seen were completed in March 2009, August 2009 and September 2009. The outcomes of these questionnaires had not been collated and therefore practice could not be reviewed in the light of feedback. We were provided with information in the AQAA about health and safety checks conducted at the service. As we were concerned about the fire doors being wedged open, we looked closely at fire safety records. Weekly checks of the means of escape, fire bell, extinguishers and emergency lighting were being completed consistently. Records of fire drills and training were not dated and did not give details of the drills conducted. For example, there were no details of the response time to the bell being sounded and records of the dates on which staff had last been involved in a drill were unclear. Records demonstrated that some staff had not been involved in fire drill training since July 2007. We stressed that all staff needed to be fully aware and competent in fire drills in the interests of the safety of people using the service. We saw a letter from the fire department dated 31/07/07 which noted, minor breaches. The letter stated that, during a fire drill it took 45 seconds to evacuate one person. Confirmation that the premises can be evacuated by staff was not documented at the time of inspection. An additional letter dated 25/07/07 noted that, the above premises should develop an effective evacuation policy for all relevant persons. There was specific reference to taking into account, staff/resident ratio, and, the mobility of relevant persons. We saw that evacuation plans for individuals were on their files. Care Homes for Older People Page 28 of 36 Evidence: However, these were not dated, or signed, and they did not provide clear, up-to-date information about peoples specific moving and handling needs. We also saw that the fire risk assessment was dated 18/10/06, and was completed by the administrator/deputy manager. The manager said that she knew that the handyperson had completed a fire risk assessment since this time. When asked about this, the handyperson explained that a tour of the building had been conducted in the last year to do the fire risk assessment. When asked where this record of the fire risk assessment was, the handyman said that it had not been recorded. It was stressed that not recording an up-to-date fire risk assessment to be used as a working tool for staff meant that people using the service and staff were being put at risk. It was advised that the manager contact the fire department for up-to-date advice on the completion of the fire risk assessment. Care Homes for Older People Page 29 of 36 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 30 of 36 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 29 19 That a POVA First Check is 18/09/2009 obtained for all staff, for whom a CRB check is not yet in place. Appropriate and timely POVA First and CRB checks must be in place for all staff who are working with vulnerable people in order that people are safeguarded from harm and poor practice. 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 Care plans must always 12/10/2009 clearly detail all the needs and support requirements of people who use the service and how those needs are to be met These needs must be regularly reviewed, and the outcomes recorded, in the light of changing needs of individuals and the advice of health care professionals, to form a daily working tool for staff. This is necessary to ensure that staff are consistently aware of the current needs of people, so that their Care Homes for Older People Page 31 of 36 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 support of each individual is always based on complete and up to date information to enable them to fully safeguard people. 2 8 13 The healthcare needs of 12/10/2009 people, including nutritional needs, tissue viability needs and moving and handling needs, must always be based on the current expert advice of health care professionals and care plan records must always contain enough up to date information for staff about what dressings/ equipment is being used and how it should be used/ maintained. In addition, a full and detailed assessment of risks to each individual must always be completed, recorded and kept under review. This is necessary in order that people always receive care and support which maintains their health and wellbeing and safeguards them from harm. 3 18 13 Robust procedures and appropriate staff training in, and understanding of, the protection of vulnerable 12/10/2009 Care Homes for Older People Page 32 of 36 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 adults from abuse must be in place. This is necessary in order that the policies and practices of the home ensure that people are safeguarded from harm. 4 19 23 The manager must ensure that the premises consistently meets the fire departments required standards. This is necessary in order that people are consistently protected from the risk of fire. 5 29 19 The manager must make sure that a detailed employment history and appropriate references are consistently taken. This is necessary to ensure that people who use the service are supported by staff who are being vetted to ensure the protection of people. 12/10/2009 12/10/2009 Care Homes for Older People Page 33 of 36 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 3 It is strongly recommended that a separate form be developed specifically for recording the outcome of pre admission assessments, so that any information obtained prior to admission is clearly recorded at the time of the assessment visit and could therefore be used to determine whether the persons needs could be met at the home. It is strongly recommended that the medication policy is updated to include the arrangements for the use of, homely remedies. Nurses training in the administration of medication should also be regularly updated and their practice monitored and reviewed. This is necessary to ensure that people receive their medication safely. It is strongly recommended that the range of activities at the home is reviewed and extended to better meet peoples social needs. It is strongly recommended that information about each individuals likes and dislikes concerning food are consistently recorded. This is necessary to ensure that staff always have the information they need to offer people the food of their choice. It is strongly recommended that peoples preferred foods are recorded and that the menus are reviewed to provide alternative choices at all meals served, to enable people using the service to make meaningful choices. It is strongly recommended that the complaints procedure is reviewed to make it more user-friendly for people and to include the details of Oldham Council, the Ombudsman and the Care Quality Commission. It is also recommended that the outcomes of all complaints are recorded in the complaints record. This is necessary in order that the complaints procedure is accessible to all people and so that people can be assured that the manager can note any patterns in problems. It is strongly recommended that staffing levels at the service are reviewed in the context of the dependency levels of people using the service and the layout of the home. This is necessary in order that staff have enough time to deliver care to each individual. 2 9 3 12 4 15 5 15 6 16 7 27 Care Homes for Older People Page 34 of 36 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 8 30 It is recommended that the outcome of staff induction and supervision is consistently recorded. This is necessary to ensure that people are cared for by staff who know how they are progressing in their work and what they need to do to improve the way they work. It is strongly recommended that the manager ensures that she reports all issues which have an impact on people using the service in accordance with Regulation 37. This is necessary to ensure the safety and well-being of people using the service. It is strongly recommended that the manager undertakes periodic training and development, to maintain and update her knowledge, skills and competence while managing the home and that a record is held of this training and development. This is necessary to ensure that staff are provided with appropriate leadership, support and guidance to enable them to care for people at the home. It is recommended that the manager undertakes quality assurance audits annually, which are based on seeking the views of people who use the service, their family and friends, staff and stakeholders within the community and publishing the outcome of the audits. This is necessary to ensure that the manager has information from all relevant parties which will allow her to develop the service. 9 37 10 37 11 38 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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