Inspection on 04/11/09 for Plane Tree Court Care Village

This inspection was carried out on 4th November 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Plane Tree Court Care Village 01/07/08

Plane Tree Court Care Village 17/08/07

Plane Tree Court Care Village 12/03/07

Plane Tree Court Care Village 25/04/06

Plane Tree Court Care Village 15/11/05

Plane Tree Court Care Village 14/06/05

Plane Tree Court Care Village 16/12/04

Plane Tree Court Care Village 13/07/04

Plane Tree Court Care Village 19/01/04

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 17/02/2010.

Key inspection report Care homes for older people Name: Address: Plane Tree Court Care Village 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX     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: Fiona Bryan     Date: 0 4 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 35 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 35 Information about the care home Name of care home: Address: Plane Tree Court Care Village 11 St. Lesmo Road Edgeley Stockport Cheshire SK3 0TX 01614806919 01612863175 richard.lake@opulenthomes.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Altruistic Care Limited care home 66 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 categories of service only. Care home with Nursing - code N, to people 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 people who can be accommodated is: 66 Date of last inspection Brief description of the care home Plane Tree Court is a large, detached building set in its own grounds in Edgeley, a suburb of Stockport. There are local amenities situated close by. Altruistic Care Limited owns the care home. The directors of the company are Mr and Mrs Jivraj. The care home has a passenger lift to assist service users to mobilise to the upper Care Homes for Older People Page 4 of 35 Over 65 66 0 0 66 Brief description of the care home floors. Lounge and dining areas are situated on the ground floor with an additional lounge and dining rooms on the first floor. The home accommodate a maximum of 66 people. The fees for staying at the home vary from £350 to £900 per week. Care Homes for Older People Page 5 of 35 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, which included a visit to the home, took place on Wednesday 4th November 2009. The staff at the home did not know that this visit was going to take place. All the key standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people living at the home, the manager and other members of the staff team. Key standards refers to those standards we feel are particularly important in ensuring the health, safety, welfare and quality of life of people living at the home. The care and services provided to five residents were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and care records was examined, including peoples care files, Care Homes for Older People Page 6 of 35 training records and staff duty rotas. Concerns had recently been raised with us about how medicines were being managed at the home so a pharmacy inspector took part in this inspection. Since the last inspection the manager had left and the operations manager was in day to day control of the home. He told us he was intending to apply to us for registration as the manager. Before the previous manager left we had asked her to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what she felt they did well, and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. The manager did not fully complete the form and therefore did not show that she had a full understanding of what areas of the service needed improving. Care Homes for Older People Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: Although people had care plans these were often disorganised and confusing, making them difficult to find relevant, up to date information. Care plans and risk assessments had not always been reviewed and advice and treatment from other health care professionals was not always used to update care plans. Where reviews had taken place peoples feedback about their care had not always been acted on. We had concerns that staff were not fully following care plans so peoples health care needs were not being addressed. Systems for the management of medicines were unsafe and put people living at the home at risk that errors could be made. Although there was an activities organiser, he worked on the nursing and residential unit. People on the intermediate care unit had no opportunities for social stimulation or interaction and several told us they were bored. Additionally, social opportunities for people that spent the majority of time in bed were very limited and staff appeared too busy to spend any significant time with individuals. Although people said in general that they liked the food at the home, staff need further training about specific dietary needs. People with diabetes were not having their diets adequately controlled, which was causing instability in their medical condition. Records for people that were being fed by PEGs (tubes directly into their stomachs) were not complete so it was unclear if they were receiving appropriate nutrition. Concerns had been raised about standards of care in the home by several health care Care Homes for Older People Page 8 of 35 professionals and there had been a number of safeguarding adults investigations. Details about these incidents and other complaints were not properly recorded. A record should be kept of all complaints and investigations, together with the action taken to address the findings so the manager can show how concerns and complaints are being acted on to improve the service. The manager had not notified us about a number of these incidents and should have done, so we can be assured that the home is operating in a open and transparent way. A recent environmental health inspection had identified a significant number of shortfalls in standards of kitchen hygiene and pest control. These were being addressed at the time of our inspection and environmental health inspectors were monitoring the situation. As a result of safeguarding investigations and monitoring visits by Stockport MBC further staff training was being put in place to ensure all staff were up to date with health and safety training. More speciifc training is also needed so staff have the skills and knowledge to provide care that meets best practice for people suffering from specific medical conditions, such as diabetes and Parkinsons Disease. Since the last inspection there have been several changes of management, the last manager having left after only 5 months. The instability within the management team has meant that systems to monitor the quality of the service and ensure staff are correctly following policies and procedures for the safety of people living at the home have fallen down. Although there was evidence that some of the issues that have been highlighted were known to the owners and operation manager, actions taken to rectify the shortfalls have to date been fairly ineffective, so the same problems remain. The manager now needs to prioritise the most important aspects of care delivery that need to be addressed and ensure staff receive the training and support to make the necssary improvements. 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 35 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 35 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. The admissions process does not always ensure that peoples care needs are properly assessed and people cannot be sure they will receive the right type of care. Evidence: We looked in detail at the care being provided to 5 people. Intermediate care was provided at Plane Tree Court on a unit specifically dedicated for this purpose. People on this unit were sometimes admitted to the home as emergencies, and in these cases assessments were carried out by social workers who gave the relevant information to staff at the home; other people were admitted from hospital and information was again transferred to the home with the person and staff used it to complete peoples admission assessments. However, assessment information was sometimes duplicated or incomplete making it difficult for the reader to get a complete picture of each persons needs. Information was sometimes missing for areas such as mental health, moving and handling, cultural and spiritual needs, pain control and oral health. Care Homes for Older People Page 11 of 35 Evidence: On the nursing unit one person was admitted to the home on 24/7/09 but the preadmission assessment was dated 25/7/09 indicating that the assessment was carried out after the person came into the home. We had concerns that people on the intermediate care unit were not being supported sufficiently to ensure that when they returned home they had the knowledge and information they needed to stay well and prevent further hospital admissions. For example, there was little evidence to show that one person with diabetes was being properly supervised and supported to manage her diet, meaning that there was no effective stabilisation of her diabetes which was the reason for her admission. How peoples health care needs were met is discussed more fully in the next section. Care Homes for Older People Page 12 of 35 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. Some people were not receiving the care they needed and the standard of handling medicines was poor and placed people living in the home at risk of harm. Evidence: Since the last inspection the home has been subject to a safeguarding adults investigation undertaken by the contract and performance manager for Stockport MBC, following concerns raised by members of the intermediate care team (professionals such as the physiotherapists, district nurses and occupational therapists who visit the home on a regular basis to provide advice and treatment for people receiving care). The intermediate care team had concerns about standards of care on the intermediate care unit and following the safeguarding investigation and subsequent monitoring an action plan was agreed with the manager in order to make the necessary improvements. As a result of this the manager told us that staff were in the process of reviewing and updating each persons care file information and transferring it to a new system, which would make it easier for the reader to extract information from and for the staff to Care Homes for Older People Page 13 of 35 Evidence: keep up to date. We looked in detail at the care provided to 5 people. One of the care files was in the new format and the information was clearer, although some aspects of the persons care needs were still incomplete, for instance there were no details about their social background, former interests or employment etc. This type of information is important in order for staff to understand people as individuals and meet their diverse needs. The care files for the other 4 people we looked at were generally confusing and haphazard. Risk assessments were duplicated and one persons care plans had not been reviewed since July 2009. This person had been prescribed oxygen in August 2009, but there was no care plan to explain why it was needed or in what circumstances it should be used. We had concerns that staff did not always follow the actions stated as being required in peoples care plans. For example, the care plan for one person at risk of pressure ulcers told staff to ensure the pressure mattress was working properly. However, when we looked at the mattress the pressure was set too high for the persons weight, which meant it may not effectively reduce the risk of the person developing sore skin and may have actually increased the risk. Although one person had had a review by Stockport MBC in October 2009, issues that were raised at the review had not been addressed a month later although they were simple requests such as turning the persons bed round so they could look out at the garden and making sure they had access to the nurse call system. This persons diverse needs that resulted from her staying in bed were not being addressed in a person centred way. We found that diabetic care in the home was unsafe because diabetic care plans were not developed to provide staff with clear instructions about how people should be supported to maintain their blood sugar levels within safe parameters. We found that knowledge about diabetic care was generally poor in relation to consistent monitoring, diet, and responding to the outcome of health checks. Instructions concerning diabetic care were ineffective in that they were contradictory and unclear. This was having a detrimental effect on peoples health. For example we noted that one person with diabetes had eaten cereal and a cooked breakfast, fish and chips and sponge and custard for lunch and gammon and pork pie, jelly and ice cream for tea, with biscuits mid morning and afternoon and rice pudding and cake in the evening. This person had gained a significant amount of weight but staff had not identified this as a cause for concern. Care Homes for Older People Page 14 of 35 Evidence: We found that in general health care was provided in a timely manner, and that people felt that that their health was looked after. Prescriptions and correspondence confirmed that people attended hospital out patient appointments, were seen by the chiropodist, dentist and opticians and other health care specialists as needed. However, instructions and advice given by other health care professionals was not always used to update care plans and there was little evidence that staff were acting on it. For example one person had been seen by the speech and language therapist (SALT) who said that they could sip small amounts of water to keep their mouth fresh and try small amounts of stage 2 diet. This advice was not on the care plan and when we spoke to the person they told us they were not given any fluids by mouth and their mouth looked dry and their breath smelled. We saw that some care files had been checked (audited) and a list of shortfalls in the records had been made for staff to follow up and bring up to date. However, this had not been done so records remained inaccurate and limited in detail. On the intermediate care unit, the intermediate care team had written intervention plans for several people, with care advice for staff working on the unit. It was not always clear from the daily records if this care was being carried out in practice and there was no information to show whether the persons condition was improving etc. As stated in the previous section we had concerns that people on the intermediate care unit were not being supported sufficiently to promote their independence and choice. We observed one person using a wheelchair who was trying to leave the lounge, who was asked by staff where he was going and when he replied that he was going to his room he was told he was not able to go to his room and the staff member wheeled him back into the lounge. We looked at how medication was stored, administered and recorded. We checked the storage areas and a sample of stock and records. We found that medicines were generally stored safely and securely in order to prevent them from being misused. Medicines requiring special storage conditions such as insulin were not always kept at the correct temperature which means that they may spoil and be unsafe to use. When we checked the records against the stocks we found that some medicines had been signed for, but not actually given whilst other medicines were missing and could not be accounted for. We found that 3 people had not had some of their medicines Care Homes for Older People Page 15 of 35 Evidence: because there was no stock available and we also saw records showing that 2 people had been given more medication than prescribed. For example one person was without their stomach medication for seven days, whilst two people were given more than the recommended daily dose of paracetamol. Failure to give medication at the prescribed dose places the health and welfare of people living in the home at serious risk of harm. We found that medicines were not always given at the correct time. Some medicines need to be taken at certain times, for example before food if they are to work properly. We saw that medicines due to be taken before breakfast were not usually given until 10am and on the day of the visit, some people were not given their morning medicines until lunchtime. Failure to administer medication at the correct time of day or at the correct time with regard to food and drink intake places the health and wellbeing of people at risk of harm. This is especially true for diabetics, people suffering from Parkinsons disease and those needing regular pain relief. Some medicines, for example painkillers were prescribed to be taken only when required. There was no written guidance for staff to follow that detailed how and when these were to be given. Without such information, staff are unable to give these medicines safely and consistently, this is particularly true for those residents who have difficulty in communicating their needs. Some people were given their nutrition and medication by PEG tubes (these are tubes that go directly into the stomach). There was little or no guidance available telling staff how these medicines should be administered and no evidence that consent had been obtained to give medicines by this route. The health and well being of people with PEG tubes is at serious risk of harm if medication and artificial feeds are not administered safely. We found that people in the intermediate care unit were not routinely assessed or encouraged to look after their own medicines. This means that on discharge, these people may not have the skills necessary to manage their medicines safely. The home had recently been visited by a pharmacist from the Primary Care Trust. He had highlighted a number of areas of weakness regarding how the home handled medication and made recomendations for improvement. The manager said that an action plan was being developed as a result of this visit, but so far few changes had been made. Some audits (checks) were undertaken, including stock balances, but these were often inaccurate and there was no evidence that action had been taken to resolve issues Care Homes for Older People Page 16 of 35 Evidence: that were highlighted. Regular audits to check all aspects of medicines management within the home are essential if the standard of handling medicines is to improve. Care Homes for Older People Page 17 of 35 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. Lack of person centred planning means that individual dietary and social care needs are not always met. Evidence: An activities organiser works at the home and an activities programme displayed in the nursing and residential unit showed a wide range of varied activities, including chair yoga, evening dances, going out for breakfast at Morrisons, afternoon walks, Holy Communion, a reading group, tea dances, trips to garden centres, pubs and local towns, bingo, fish and chips suppers and games such as Pictionary. We observed the activities organiser leading a group discussion about current affairs and noticed an excellent rapport between him and the people living at the home. Several people told us that after lunch they were going to the town hall for a tea dance, which they were looking forward to. None of the care files that we looked at provided details about peoples life histories and there was little information about their social care needs, preferences and interests. Daily records did not generally show how people had spent their day. Care Homes for Older People Page 18 of 35 Evidence: People on the intermediate care unit said there was little going on in the home that they could join in with and the manager said that activities were not given a high priority on that unit as people were only coming for short stays and many of them had regular visitors during that time; however, visiting times were restricted on this unit. The manager reported that as the activities organiser had limited time the decision had been made that this would be best spent with people that were living at the home permanently. The manager said that they were planning to recruit a second activities organiser and develop an activities programme for the intermediate care unit. We had concerns that people that spent the majority of the day in bed or in their rooms did not receive enough social interaction and stimulation. One person told us she was bored and other comments included You can borrow library books otherwise it would drive you daft and there is not enough going on to entertain you, mostly watching TV. We just stagnate. More consideration should be given as to how peoples social care needs can be met in a way that meets their individual abilities and preferences, especially for those that do not want to, or are unable to join in with group activities. People generally said they liked the food provided at the home. We looked at the menus and saw that a choice was provided at each mealtime. Lunch on the day of the inspection was savoury mince or fishcakes, chips or mashed potatoes and peas, followed by egg custard. Options at tea time were braised steak and onion, potatoes, broccoli and carrots or leek soup and sandwiches followed by scones and fruit cake. We saw staff asking people during the morning what they wanted for lunch and tea. Staff need to be aware of peoples abilities when serving the meals. We observed a carer serving one person his meal and giving him a knife and fork although he was unable to use his right arm at all. This person would also have benefited from a plate guard to enable him to get the food off the plate more easily. As stated in the previous section we had concerns that people with diabetes were not receiving adequate advice and supervision regarding their diet and this was having a detrimental effect on the management of their blood sugar levels. The chef and staff need more information about best practice in relation to providing a healthy diet for people who are diabetic. Care Homes for Older People Page 19 of 35 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 procedures within the home were not strong enough to ensure that people living there were safeguarded from abuse. Evidence: Since the last inspection there have been a number of safeguarding referrals and investigations regarding the care provided at the home. The manager did not tell us that these investigations were going on. We attended some of the meetings that were held about various incidents and people living at the home. Some investigations are still ongoing. The outcome of one investigation found that on the intermediate care unit staff had failed to identify pressure sore areas and that staff were not adequately trained to do this. Poor practice was also identified in medicines management and moving and handling. Another safeguarding investigation concluded that the person involved had been subject to abuse in respect of failure to meet their nutritional and social care needs. Subsequent monitoring visits have indicated that whilst there had been an attempt to make some improvements these did not go far enough and there was a lack of confidence that the necessary improvements could be made. From the evidence we found at this inspection it appeared that many of the issues Care Homes for Older People Page 20 of 35 Evidence: identified during the safeguarding investigations remain a cause for concern. The reasons for this are discussed in the management section of this report. The manager had no proper record of any complaints/safeguarding incidents to show how they had been addressed. This meant that the manager could not demonstrate how complaints were dealt with and how they were used to develop and improve the service provided at the home. Care Homes for Older People Page 21 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment was not as comfortable as it could be for people living at the home. Evidence: We found that the communal areas were clean, the chairs and furniture were in good repair and free from unsightly stains which meant that they were pleasant to use. We noted that some aspects of the communal areas were cramped and suitable furniture was not ready to hand. For example during lunch staff placed large jugs of drink on the floor because there was no space for a sideboard or table. This could have been overcome if jugs of juice had been placed on each table so that people helped themselves. A partial tour of the home was completed. Most areas of the home were clean and tidy although one or 2 individual rooms had a bad smell and we saw one of the cleaners walking down the hallway spraying air freshener extensively, which created a strong, irritating chemical smell. Despite having a number of different lounges it seemed that the majority of people living at the home were squashed into just one or two. One small lounge was extremely hot and people were sat in wheelchairs right underneath the flat screen TV which was fixed to one wall. The atmosphere was therefore cramped and Care Homes for Older People Page 22 of 35 Evidence: uncomfortable. Approximately another 7 people were crowded into another small lounge, that had too much furniture. Although the AQAA said that an activities room had been created, this in fact had been changed into a bedroom. One of the bedrooms was being used to hold a group discussion during our visit, rather than using one of the communal rooms. The manager should review the communal rooms within the home and consider whether how they are used can be improved. Peoples rooms were spacious and comfortable. People had been encouraged to personalise their rooms with their own possessions. During the tour of the building we noted that signage was very poor or none existent in relation to directing people to different facilities in the home such as sitting room, dining room, bathroom or toilet. Peoples sense of wellbeing may be improved if steps are taken to make the corridors less confusing so that it is easier for them to find their way around the home independently, without taking wrong turns and having to ask staff for directions. We noted that all the corridors looked the same, however, peoples names had been put on bedroom doors. These were in large lettering which was helpful to the residents. A food hygiene inspection and a health and safety at work inspection was carried out by the environmental health inspectors on 13/10/09. A large number of issues were found where the home was failing to comply with legislation in relation to Hazard Analysis and Critical control Point(HACCP) principles, equipment hygiene, food protection from contamination, temperature control of food, hand washing facilities, personal hygiene, lighting, ventilation and pest control. The inspectors made a formal summary of actions that were required. The associate director of the company confirmed that all the issues had been addressed. Care Homes for Older People Page 23 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lack of organisation and sufficient staff training means that people have not always received the care they needed. Evidence: We looked at the staff duty rotas for the month of October 2009. In general these showed that on the intermediate care unit there was a total of 5 care staff including the unit manager and/or a senior carer on duty during the day caring for up to 21 people. On the nursing and residential unit there was usually 1 nurse and 7 carers looking after up to 44 people living on 2 floors. On the day of our inspection there was only 1 nurse and 6 carers on the nursing and residential unit but staff confirmed there were usually 7 carers. At night there were 2 carers working on the intermediate care unit and 1 nurse and 3 carers working on the nursing and residential unit. The manager should review the numbers of staff required especially on the nursing and residential unit; we were of the opinion that due to the high level of needs of people living on this unit the numbers of staff were only just sufficient. We heard nurse call bells ringing for some time before they were answered and one person said Staff pass the lounge but they dont come in, its very frustrating. We looked at two staff personnel files. Both contained CRB disclosures, POVA First checks and appropriate references. One person had not supplied enough detail about Care Homes for Older People Page 24 of 35 Evidence: their previous employment history and had also not provided documentary evidence of their qualifications and training. This type of evidence is required so the manager can be satisfied on reasonable grounds as to the authenticity of the information supplied and the fitness of the person to work in the home. In response to the safeguarding investigation, which found that staff had not had sufficient training in a range of topics, the manager said that additional training had started. A training matrix showed that 34 staff had undertaken training in moving and handling since July 2009, 3 staff had undertaken training in infection control in September 2009 and another 30 staff had done the training earlier this year and staff had received training in Health and Safety and Safeguarding Adults. Other training topics that were entered on the matrix included training in the Malnutrition Universal Screening Tool (MUST), pressure area care and catheter care although few staff appeared to have completed this training. It was reported that some training was provided by external trainers such as Stockport MBC (safeguarding) and that another home manager from within the group was coordinating the training to ensure all staff had refresher training in all relevant areas. A lot of the training took the form of DVDs, which the staff watched and then completed multiple choice tests afterwards to check their understanding. We noted that it had been determined on the matrix that training in Equality and Diversity was not necessary for ancillary staff; as good practice it would be useful for all staff that come into contact with people living at the home to be given this training so that everyone is aware of the importance of respecting peoples individuality and that ethos can be embedded in the culture of the home. There was no evidence that staff had received training in other topics that were specific to the needs of the people they were caring for, such as diabetes. Training must be delivered to equip staff with the skills and knowledge they need to provide appropriate care to people with specific health conditions. The AQAA was not fully completed and did not give details about the number of staff who had NVQs. Although we asked the manager to provide this information, at the time of writing this report it had not been given. Care Homes for Older People Page 25 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems do not ensure the efficient running of the unit and the ongoing improvement of the service. Evidence: Since the last inspection the manager had resigned and the operations manager had taken taken over day to day control of the home. It was reported that he would be applying for registration with us as the home manager. Over the past few months a number of concerns had been raised by various health and allied care professionals that visit the home. Concerns related to the standard of care being provided to people, especially in respect of nutritional and pressure area care, staffing levels and staff training, systems of communication, medicines management and the degree of social interaction and stimulation being provided for some people. There had been some safeguarding investigations, which found that in some cases staff had failed to deliver the expected level of care. Care Homes for Older People Page 26 of 35 Evidence: An audit system was in place which covered various areas such as home presentation, medicine management, care records, complaints management, staff recruitment and personnel files, health and safety, staff training and social activities amongst others. However, it was of concern that the audit of June 2009 appeared to identify some of the issues that were later highlighted by other professionals as being a cause for concern; despite identification of shortfalls actions that had been taken to address them appeared to have been ineffective. The last audit was undertaken by the present manager and this generally confirmed many of the issues identified through the safeguarding investigations and subsequent monitoring visits. The manager reported that having gone through the auditing process for himself he was now trying to work through the comprehensive action plan developed by the contract and performance manager from Stockport MBC. The manager did say that because the home had been subject to a high level of scrutiny he was finding it difficult to allocate time to working through the action plan in a logical way because he was having to deal with the large number of visitors to the home that were created as a result of the safeguarding investigations and monitoring. The manager felt that he needed to address all the concerns in order of priority and wanted to spend time initially ensuring that peoples health, personal and social care needs were being met and recorded properly and we agreed that the necessary improvements needed to be made in a structured and organised way. Since the last inspection a separate bank account has been set up for the use of people living at the home. Large sums of money can be deposited in the bank and a small float of cash is kept for the immediate use of anyone requiring access to their money. It was reported that each person had a separate balance sheet and that receipts were kept for all itemised transactions. We did not view these records at this inspection. We are aware that there have been a number of incidents within the home that have not been reported to us under Regulation 37 of the Care Homes Regulations 2001. The manager must ensure that all notifiable incidents are reported to us without delay so we can be assured that the management of the home is based on transparency and openness. As stated previously, a recent environmental health inspection highlighted numerous shortfalls which potentially put staff and people living at the home at risk. An audit system should be developed to ensure that shortfalls are highlighted internally, so that further issues are not identified at future inspections by the environmental health Care Homes for Older People Page 27 of 35 Evidence: officers. The AQAA was completed by the previous manager and did not provide enough information to demonstrate to us that the manager could identify what the home did well, what areas needed further improvement and how future plans could address them. Parts of the AQAA were not completed. Care Homes for Older People Page 28 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must address all 31/12/2009 aspects of peoples health, personal and social care needs and must be reviewed regularly to ensure they are up to date and accurate. Staff must ensure that actions stated as being required in the care plans are followed in practice. This will ensure that staff have the information to provide an appropriate level of care for people and to understand how it will be monitored. 2 8 13 Staff must ensure that they follow the advice and treatment prescribed by other health care professionals and must seek advice if they require additional support in the management of specific conditions eg diabetes. 31/12/2009 Care Homes for Older People Page 30 of 35 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure that people receive care and treatment that meets current best practice. 3 9 13 There must be clear instructions detailing how medication is to be administered to people with PEG tubes in place. Consent to administer medication by this route must be obtained from the prescriber. This is to ensure that these people receive their medication and nutrition safely. 4 9 13 There must be robust systems in place for reordering medication so that medicines do not run out This is to ensure that people do not miss their medicines uneccesarily 5 9 13 Medication must be administered as prescribed, particularly with regard to food and drink intake This is to ensure that people receive their medicines correctly 31/12/2009 31/12/2009 31/12/2009 Care Homes for Older People Page 31 of 35 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 6 9 13 Medicines must be kept at the correct temperature as recommended by the manufacturers This is to ensure it does not spoil and is safe to use 31/12/2009 7 9 13 There must be regular audits 31/12/2009 to assess all aspects of medicines management within the home. The findings and actions taken as a result of the audits must be recorded This is to ensure that the standard of medicines management is regularly checked and improvements made where necessary 8 18 13 The manager must ensure that actions identified as being required from safeguarding investigations are implemented and robust systems are put in place to ensure that improvements are sustained. This will ensure that areas that were highlighted as causes for concern are addressed and the risk of harm or abuse for people living in the home are reduced. 31/12/2009 Care Homes for Older People Page 32 of 35 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 9 30 18 Staff must receive training 28/02/2010 appropriate to the work they are to perform. This includes training in specific care needs such as the management of diabetes, nutritional care, pressure area care and rehabilitative techniques for people staying on the intermediate care unit. This will ensure that staff have the skills and knowledge to deliver care appropriately. 10 33 24 The manager must develop an effective quality monitoring system to ensure that staff are following the correct policies and procedures and to identify and address shortfalls in the service so they can be addressed. This will ensure that the home is run in the best interests of the people living there. 31/01/2010 Care Homes for Older People Page 33 of 35 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 People should only be admitted to the home on the basis of a full assessment, which includes all aspects of their health, social, mental and personal care needs. Staff should ensure that people are supported to make choices and exercise independence so they maintain living skills. Staff should ensure that medication fridges are within the recommended temperature range of 2-8C at all times. Staff should assess and support people to manage their own medication safely, particularly in the intermediate care unit. There should be clear written guidance for medicines to be taken only when required to ensure these medicines are given correctly and consistantly. 2 8 3 9 4 12 Arrangements should be made to ensure that all people living at the home have opportunities for social interaction and stimulation, including those people that are confined to bed and people staying on the intermediate care unit. A record should be kept of all complaints made, with details of how they were investigated and responded to so the manager can demonstrate how people are listened to and their feedback used to improve the service. The manager should review the use of communal rooms in the home to ensure their function meets the needs of people living there. Signage around the home should be improved to help people find their way around. The manager should consider the dependency of people living at the home when determining staffing levels to ensure they are appropriate to meet peoples needs. The manager should ensure that all relevant information and documents are obtained prior to employing staff so an accurate assessment can be made about their fitness for the post. 5 16 6 19 7 27 8 29 Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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